Provider Demographics
NPI:1760759617
Name:CONVIENENT CARE CLINIC
Entity Type:Organization
Organization Name:CONVIENENT CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:MCCALLUM
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:731-445-9406
Mailing Address - Street 1:2490 PARR AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-2029
Mailing Address - Country:US
Mailing Address - Phone:731-286-8007
Mailing Address - Fax:731-286-8019
Practice Address - Street 1:2490 PARR AVE STE 3
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-2029
Practice Address - Country:US
Practice Address - Phone:731-286-8007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-21
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13555261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ008468Medicaid