Provider Demographics
NPI:1518106020
Name:TIDWELL FAMILY VENTURES LLC
Entity Type:Organization
Organization Name:TIDWELL FAMILY VENTURES LLC
Other - Org Name:PORTLAND FAMILY CARE AND WALK-IN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:615-323-1020
Mailing Address - Street 1:505 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148-1438
Mailing Address - Country:US
Mailing Address - Phone:615-323-1020
Mailing Address - Fax:615-323-1021
Practice Address - Street 1:505 S BROADWAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-1438
Practice Address - Country:US
Practice Address - Phone:615-323-1020
Practice Address - Fax:615-323-1021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-08
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1755207Q00000X
TN10971363LA2100X
TN13982363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty