Provider Demographics
NPI:1467957126
Name:ADVANCED FAMILY MEDICAL CENTER
Entity Type:Organization
Organization Name:ADVANCED FAMILY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:V
Authorized Official - Last Name:CAICEDO
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:731-518-7391
Mailing Address - Street 1:101 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:TN
Mailing Address - Zip Code:38052-3433
Mailing Address - Country:US
Mailing Address - Phone:731-472-2147
Mailing Address - Fax:731-472-2148
Practice Address - Street 1:101 MAIN ST N
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:TN
Practice Address - Zip Code:38052-3433
Practice Address - Country:US
Practice Address - Phone:731-472-2147
Practice Address - Fax:731-472-2148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-26
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR1300X
TN17787363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ001019Medicaid