Provider Demographics
NPI:1194023366
Name:COMMUNITY QUICK CARE OF LAVERGNE, PC
Entity Type:Organization
Organization Name:COMMUNITY QUICK CARE OF LAVERGNE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:P
Authorized Official - Last Name:ELEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-943-5072
Mailing Address - Street 1:PO BOX 2684
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37024-2684
Mailing Address - Country:US
Mailing Address - Phone:615-943-5072
Mailing Address - Fax:615-527-0270
Practice Address - Street 1:5148A MURFREESBORO RD
Practice Address - Street 2:
Practice Address - City:LA VERGNE
Practice Address - State:TN
Practice Address - Zip Code:37086-2712
Practice Address - Country:US
Practice Address - Phone:615-213-1203
Practice Address - Fax:615-527-0270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-11
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN339630207Q00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103G705434Medicare PIN