Provider Demographics
NPI:1861844763
Name:FAMILY AND PEDIATRIC CARE CLINIC LLC
Entity Type:Organization
Organization Name:FAMILY AND PEDIATRIC CARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-569-2754
Mailing Address - Street 1:PO BOX 681
Mailing Address - Street 2:
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779-0681
Mailing Address - Country:US
Mailing Address - Phone:828-339-7253
Mailing Address - Fax:828-586-8209
Practice Address - Street 1:19067 ALBERTA ST
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:TN
Practice Address - Zip Code:37841-6002
Practice Address - Country:US
Practice Address - Phone:423-569-2754
Practice Address - Fax:423-569-2756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-05
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000020552363LF0000X
TN0000016521363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6080615OtherBCBS TN
TNQ025132Medicaid
TN103G741696OtherTN MEDICARE