Provider Demographics
NPI:1659514776
Name:AMG CROCKETT LLC
Entity Type:Organization
Organization Name:AMG CROCKETT LLC
Other - Org Name:FIRST CHOICE HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:106 S MILITARY AVE
Mailing Address - Street 2:
Mailing Address - City:LORETTO
Mailing Address - State:TN
Mailing Address - Zip Code:38469-2101
Mailing Address - Country:US
Mailing Address - Phone:931-853-4622
Mailing Address - Fax:931-853-4621
Practice Address - Street 1:106 S MILITARY AVE
Practice Address - Street 2:
Practice Address - City:LORETTO
Practice Address - State:TN
Practice Address - Zip Code:38469-2101
Practice Address - Country:US
Practice Address - Phone:931-853-4622
Practice Address - Fax:931-853-4621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty