Provider Demographics
NPI:1538671631
Name:QUALLS HARBIN FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:QUALLS HARBIN FAMILY MEDICINE LLC
Other - Org Name:HOMETOWN HEALTH CLINIC LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:FNP/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARBIN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:731-438-3765
Mailing Address - Street 1:PO BOX 445
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:TN
Mailing Address - Zip Code:38372-0445
Mailing Address - Country:US
Mailing Address - Phone:731-438-3765
Mailing Address - Fax:731-438-3767
Practice Address - Street 1:255 RIVERSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:TN
Practice Address - Zip Code:38372
Practice Address - Country:US
Practice Address - Phone:731-438-3765
Practice Address - Fax:731-438-3767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-30
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000021321363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ032778Medicaid
TN1538671631OtherNPI