Provider Demographics
NPI:1124496575
Name:TOTAL HEALTH MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:TOTAL HEALTH MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP/CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:901-610-3135
Mailing Address - Street 1:1204 W POPLAR AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-3103
Mailing Address - Country:US
Mailing Address - Phone:901-610-3135
Mailing Address - Fax:
Practice Address - Street 1:1204 W POPLAR AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-3103
Practice Address - Country:US
Practice Address - Phone:901-610-3135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-02
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18449363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ018654Medicaid