Provider Demographics
NPI:1003302951
Name:FAITH FAMILY MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:FAITH FAMILY MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:CALLERY
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, FNP-C
Authorized Official - Phone:731-734-2023
Mailing Address - Street 1:511 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38012-4113
Mailing Address - Country:US
Mailing Address - Phone:731-734-2023
Mailing Address - Fax:877-753-3133
Practice Address - Street 1:511 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38012
Practice Address - Country:US
Practice Address - Phone:731-734-2023
Practice Address - Fax:877-753-3133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-03
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ037097Medicaid