Provider Demographics
NPI:1437623337
Name:PINELAKE PHYSICIAN PRACTICE, LLC
Entity Type:Organization
Organization Name:PINELAKE PHYSICIAN PRACTICE, LLC
Other - Org Name:
Other - Org Type:
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:615-920-7000
Mailing Address - Fax:
Practice Address - Street 1:101 MAIN ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:KY
Practice Address - Zip Code:42041-1601
Practice Address - Country:US
Practice Address - Phone:270-472-5245
Practice Address - Fax:270-472-5249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-14
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health