Provider Demographics
NPI:1689604365
Name:SYCAMORE VALLEY ACQUISITION COMPANY, PLLC
Entity Type:Organization
Organization Name:SYCAMORE VALLEY ACQUISITION COMPANY, PLLC
Other - Org Name:SYCAMORE VALLEY MEDICAL GROUP, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-792-1911
Mailing Address - Street 1:313 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37015-1319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:313 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ASHLAND CITY
Practice Address - State:TN
Practice Address - Zip Code:37015-1319
Practice Address - Country:US
Practice Address - Phone:615-792-1911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3721906Medicaid
TN3721906Medicaid