Basic Information
Provider Information | |||||||||
NPI: | 1912587932 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILY CARE WALK IN CLINIC, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15001 S 1ST ST | ||||||||
Address2: |   | ||||||||
City: | MILAN | ||||||||
State: | TN | ||||||||
PostalCode: | 383585132 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7316132535 | ||||||||
FaxNumber: | 7316132534 | ||||||||
Practice Location | |||||||||
Address1: | 15001 S 1ST ST | ||||||||
Address2: |   | ||||||||
City: | MILAN | ||||||||
State: | TN | ||||||||
PostalCode: | 383585132 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7316132535 | ||||||||
FaxNumber: | 7316132534 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/13/2021 | ||||||||
LastUpdateDate: | 04/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HUNT | ||||||||
AuthorizedOfficialFirstName: | HELEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING/CREDENTIALING | ||||||||
AuthorizedOfficialTelephone: | 7316132535 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
ID | Type | State | Issuer | Description | 3378522 | 05 | TN |   | MEDICAID |