Provider Demographics
NPI:1851490841
Name:CONVENIENT CARE CLINIC, PLLC
Entity Type:Organization
Organization Name:CONVENIENT CARE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR OF REVENUE
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-864-8713
Mailing Address - Street 1:30 BURTON HILLS BLVD
Mailing Address - Street 2:SUITE 175
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6403
Mailing Address - Country:US
Mailing Address - Phone:615-864-8713
Mailing Address - Fax:
Practice Address - Street 1:3040 GOODMAN RD WEST
Practice Address - Street 2:
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-2474
Practice Address - Country:US
Practice Address - Phone:662-578-2030
Practice Address - Fax:615-301-6550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015109Medicaid
MSC02499Medicare PIN
MSC02499Medicare PIN
MS09015109Medicaid