Provider Demographics
NPI:1518226646
Name:PA CORPORATE ENTERPRISES, LLP
Entity Type:Organization
Organization Name:PA CORPORATE ENTERPRISES, LLP
Other - Org Name:GREENFIELD FAMILY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILBERT
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:731-235-0555
Mailing Address - Street 1:801 S MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:38230-2104
Mailing Address - Country:US
Mailing Address - Phone:731-235-0555
Mailing Address - Fax:731-235-0559
Practice Address - Street 1:801 S MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:TN
Practice Address - Zip Code:38230-2104
Practice Address - Country:US
Practice Address - Phone:731-235-0555
Practice Address - Fax:731-235-0559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-09
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN 1396261QR1300X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty