Provider Demographics
NPI:1376937797
Name:TENNESSEE CONVENIENCE CARE LLC
Entity Type:Organization
Organization Name:TENNESSEE CONVENIENCE CARE LLC
Other - Org Name:TENNESSEE CONVENIENCE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LORA
Authorized Official - Middle Name:F
Authorized Official - Last Name:ELKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-526-1050
Mailing Address - Street 1:315 N WASHINGTON AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2623
Mailing Address - Country:US
Mailing Address - Phone:931-526-1050
Mailing Address - Fax:931-526-8163
Practice Address - Street 1:315 N WASHINGTON AVE STE 130
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2623
Practice Address - Country:US
Practice Address - Phone:931-526-1050
Practice Address - Fax:931-526-8163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-24
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18488207Q00000X
TN17011363L00000X
TN13278363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty