Provider Demographics
NPI:1407076060
Name:PRIMECARE CLINIC, PLLC
Entity Type:Organization
Organization Name:PRIMECARE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:NKOMAZANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-376-1851
Mailing Address - Street 1:PO BOX 479
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-0479
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 CHICKADEE AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:TN
Practice Address - Zip Code:38052-3425
Practice Address - Country:US
Practice Address - Phone:731-376-0034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25889207Q00000X
TN38934207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty