Basic Information
| Provider Information | |||||||||
| NPI: | 1851678767 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOORESVILLE PPM LLC | ||||||||
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| OtherOrganizationName: | PRIMARY CARE ASSOCIATES OF BYERS CREEK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 MERIDIAN BLVD | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370676325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154657230 | ||||||||
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| Practice Location | |||||||||
| Address1: | 128 ARGUS LN | ||||||||
| Address2: | SUITE G | ||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281176972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046631440 | ||||||||
| FaxNumber: | 7046631445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2011 | ||||||||
| LastUpdateDate: | 01/14/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SR DIR PROV ENROLLMENT & ONBOARDING | ||||||||
| AuthorizedOfficialTelephone: | 6154653334 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MOORESVILLE PPM LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5915049 | 05 | NC | MEDICAID |