Provider Demographics
NPI:1114367851
Name:ENCLAVE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:ENCLAVE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KARLTON
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-712-9809
Mailing Address - Street 1:317 SEVEN SPRINGS WAY
Mailing Address - Street 2:SUITE 230
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4575
Mailing Address - Country:US
Mailing Address - Phone:714-249-3999
Mailing Address - Fax:
Practice Address - Street 1:317 SEVEN SPRINGS WAY
Practice Address - Street 2:SUITE 230
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-4575
Practice Address - Country:US
Practice Address - Phone:714-249-3999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000037790207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty