Provider Demographics
NPI:1811543929
Name:AMG-CROCKETT, LLC
Entity Type:Organization
Organization Name:AMG-CROCKETT, LLC
Other - Org Name:FIRST CHOICE HEALTH LORETTO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:TEAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-920-7646
Mailing Address - Street 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:ATTEN: PROVIDER ENROLLMENT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5098
Mailing Address - Country:US
Mailing Address - Phone:615-920-7782
Mailing Address - Fax:615-920-8775
Practice Address - Street 1:722 N MILITARY ST
Practice Address - Street 2:
Practice Address - City:LORETTO
Practice Address - State:TN
Practice Address - Zip Code:38469-2336
Practice Address - Country:US
Practice Address - Phone:931-853-6970
Practice Address - Fax:931-853-6974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-14
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty