Provider Demographics
NPI:1538703897
Name:FAMILY MEDICAL CLINIC OF TREZEVANT
Entity Type:Organization
Organization Name:FAMILY MEDICAL CLINIC OF TREZEVANT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:LEGGETT
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:731-200-3001
Mailing Address - Street 1:45 HURT ST
Mailing Address - Street 2:
Mailing Address - City:TREZEVANT
Mailing Address - State:TN
Mailing Address - Zip Code:38258-2505
Mailing Address - Country:US
Mailing Address - Phone:731-207-0323
Mailing Address - Fax:731-240-8065
Practice Address - Street 1:45 HURT ST
Practice Address - Street 2:
Practice Address - City:TREZEVANT
Practice Address - State:TN
Practice Address - Zip Code:38258-2505
Practice Address - Country:US
Practice Address - Phone:731-207-0323
Practice Address - Fax:731-240-8065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-30
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ054230Medicaid