Provider Demographics
NPI:1124802178
Name:SUPERIORCARE MEDICAL GROUP LLC
Entity type:Organization
Organization Name:SUPERIORCARE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-403-7741
Mailing Address - Street 1:3750 HACKS CROSS RD # 102-202
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-2367
Mailing Address - Country:US
Mailing Address - Phone:662-408-6995
Mailing Address - Fax:
Practice Address - Street 1:1175 VICKERY LN STE 101
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-0682
Practice Address - Country:US
Practice Address - Phone:662-408-6995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-22
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty