Provider Demographics
NPI:1154179950
Name:MID TN CLINIC LLC
Entity type:Organization
Organization Name:MID TN CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:GABRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:615-569-4067
Mailing Address - Street 1:3413 NOLENSVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-2909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3413 NOLENSVILLE PIKE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37211-2909
Practice Address - Country:US
Practice Address - Phone:615-569-4067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute CareGroup - Single Specialty