Provider Demographics
NPI:1417102906
Name:FIRST CHOICE MEDICAL CARE OF MEDINA, INC.
Entity Type:Organization
Organization Name:FIRST CHOICE MEDICAL CARE OF MEDINA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:731-267-0239
Mailing Address - Street 1:605 HWY 45 EAST
Mailing Address - Street 2:P.O. BOX 159
Mailing Address - City:MEDINA
Mailing Address - State:TN
Mailing Address - Zip Code:38355
Mailing Address - Country:US
Mailing Address - Phone:731-267-0239
Mailing Address - Fax:
Practice Address - Street 1:605 HWY 45 EAST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:TN
Practice Address - Zip Code:38355
Practice Address - Country:US
Practice Address - Phone:731-267-0239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-25
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN33929261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3343619Medicare PIN