Basic Information
| Provider Information | |||||||||
| NPI: | 1083909204 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMPLETE EXPRESS CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1211 DINAH SHORE BLVD | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373981107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9319676669 | ||||||||
| FaxNumber: | 9319676606 | ||||||||
| Practice Location | |||||||||
| Address1: | 1211 DINAH SHORE BLVD | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373981107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9319676669 | ||||||||
| FaxNumber: | 9319676606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2011 | ||||||||
| LastUpdateDate: | 03/22/2016 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | FLOYD | ||||||||
| AuthorizedOfficialMiddleName: | DON | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9319676669 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363AM0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 261QU0200X | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 1527276 | 05 | TN | MEDICAID |