Provider Demographics
NPI:1265617674
Name:CENTENNIAL PRIMARY CARE LLC
Entity type:Organization
Organization Name:CENTENNIAL PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-767-5716
Mailing Address - Street 1:1009 N LOCUST AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38464-2706
Mailing Address - Country:US
Mailing Address - Phone:931-762-0531
Mailing Address - Fax:931-762-0998
Practice Address - Street 1:1009 N LOCUST AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464-2706
Practice Address - Country:US
Practice Address - Phone:931-762-0531
Practice Address - Fax:931-762-0998
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOSPITAL CORP. LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-03
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3370233Medicaid
TN3370233Medicare PIN
TN3370233Medicaid