Provider Demographics
NPI:1639345952
Name:THE GROVE PRIMARY CARE CLINIC LLC
Entity type:Organization
Organization Name:THE GROVE PRIMARY CARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:
Authorized Official - Last Name:WYSOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-983-0499
Mailing Address - Street 1:541 W PARK PL
Mailing Address - Street 2:SUITE C
Mailing Address - City:HENDERSON
Mailing Address - State:TN
Mailing Address - Zip Code:38340-2027
Mailing Address - Country:US
Mailing Address - Phone:731-983-0499
Mailing Address - Fax:731-983-0573
Practice Address - Street 1:541 W PARK PL
Practice Address - Street 2:SUITE C
Practice Address - City:HENDERSON
Practice Address - State:TN
Practice Address - Zip Code:38340-2027
Practice Address - Country:US
Practice Address - Phone:731-983-0499
Practice Address - Fax:731-983-0573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN443968Medicare Oscar/Certification
TN3370310Medicare PIN