Provider Demographics
NPI:1821352808
Name:EXECUTIVE OUTCOMES PC
Entity Type:Organization
Organization Name:EXECUTIVE OUTCOMES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MONICO
Authorized Official - Middle Name:P
Authorized Official - Last Name:BANEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-234-5717
Mailing Address - Street 1:560 MCCLELLAN RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-9688
Mailing Address - Country:US
Mailing Address - Phone:731-234-5717
Mailing Address - Fax:423-979-6333
Practice Address - Street 1:560 MCCLELLAN RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-9688
Practice Address - Country:US
Practice Address - Phone:731-234-5717
Practice Address - Fax:423-979-6333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-25
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty