Provider Demographics
NPI:1700192028
Name:COFFEE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:COFFEE MEDICAL GROUP LLC
Other - Org Name:CENTER FOR FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:COUCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-728-6354
Mailing Address - Street 1:1615 MCMINNVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-3179
Mailing Address - Country:US
Mailing Address - Phone:931-728-6205
Mailing Address - Fax:931-723-3194
Practice Address - Street 1:1615 MCMINNVILLE HWY
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-3179
Practice Address - Country:US
Practice Address - Phone:931-728-6205
Practice Address - Fax:931-723-3194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-24
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health