Provider Demographics
NPI:1982972857
Name:PROXIMA CENTAURI, PLLC
Entity Type:Organization
Organization Name:PROXIMA CENTAURI, PLLC
Other - Org Name:LINCOLN TREE MEDICAL CLINIC OF TULLAHOMA, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:EDWARDS
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-723-7950
Mailing Address - Street 1:PO BOX 437
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37349-0437
Mailing Address - Country:US
Mailing Address - Phone:931-723-7950
Mailing Address - Fax:931-723-7815
Practice Address - Street 1:1600 MCARTHUR ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-2522
Practice Address - Country:US
Practice Address - Phone:931-723-7950
Practice Address - Fax:931-723-7950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-07
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty