Provider Demographics
NPI:1801926217
Name:EAGLEVILLE CLINIC
Entity type:Organization
Organization Name:EAGLEVILLE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-274-6207
Mailing Address - Street 1:341 SOUTH MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAGLEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37060
Mailing Address - Country:US
Mailing Address - Phone:615-274-6207
Mailing Address - Fax:
Practice Address - Street 1:341 SOUTH MAIN ST.
Practice Address - Street 2:
Practice Address - City:EAGLEVILLE
Practice Address - State:NE
Practice Address - Zip Code:37060
Practice Address - Country:US
Practice Address - Phone:615-274-6207
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN443845Medicaid
TN443845Medicaid
TN443845Medicare ID - Type Unspecified
TNP86496Medicare UPIN