Provider Demographics
NPI:1568457851
Name:VIVIAN FAMILY MEDICAL LLC
Entity Type:Organization
Organization Name:VIVIAN FAMILY MEDICAL LLC
Other - Org Name:COOKEVILLE FAMILY MEDICINE & URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FREEDOM
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:VIVIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-520-0148
Mailing Address - Street 1:675 S JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-0949
Mailing Address - Country:US
Mailing Address - Phone:931-520-0148
Mailing Address - Fax:931-520-0152
Practice Address - Street 1:675 S JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-0949
Practice Address - Country:US
Practice Address - Phone:931-520-0148
Practice Address - Fax:931-520-0152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0770363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3725296Medicare ID - Type Unspecified