Provider Demographics
NPI:1053353771
Name:GOODLETTSVILLE PRIMARY CARE LLC
Entity type:Organization
Organization Name:GOODLETTSVILLE PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7604
Mailing Address - Street 1:318 NORTHCREEK BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-1934
Mailing Address - Country:US
Mailing Address - Phone:615-855-0437
Mailing Address - Fax:
Practice Address - Street 1:318 NORTHCREEK BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-1934
Practice Address - Country:US
Practice Address - Phone:615-855-0437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3736498Medicare PIN