Provider Demographics
NPI:1437614633
Name:PINELAKE PHYSICIAN PRACTICE LLC
Entity Type:Organization
Organization Name:PINELAKE PHYSICIAN PRACTICE LLC
Other - Org Name:JACKSON PURCHASE PRIMARY CARE - CLINTON CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIRECTOR, PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:SHARLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEBLEU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-920-7192
Mailing Address - Street 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5098
Mailing Address - Country:US
Mailing Address - Phone:615-920-7192
Mailing Address - Fax:
Practice Address - Street 1:106 W CLAY ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:KY
Practice Address - Zip Code:42031-1317
Practice Address - Country:US
Practice Address - Phone:270-653-0220
Practice Address - Fax:270-653-0221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-01
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty