Provider Demographics
NPI:1295264141
Name:SECD TALLASSEE LLC
Entity type:Organization
Organization Name:SECD TALLASSEE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:NORTHCUTT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-319-4918
Mailing Address - Street 1:1040 NATCHEZ VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37064-4704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1608 GILMER AVE
Practice Address - Street 2:
Practice Address - City:TALLASSEE
Practice Address - State:AL
Practice Address - Zip Code:36078-2314
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6397261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental