Provider Demographics
NPI:1588964811
Name:GOOD SAMARITAN FAMILY WALK-IN CLINIC, LLC
Entity type:Organization
Organization Name:GOOD SAMARITAN FAMILY WALK-IN CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:TERESA
Authorized Official - Last Name:ORTEGA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:731-215-2277
Mailing Address - Street 1:1869 HIGHWAY 45 BYP
Mailing Address - Street 2:SUITE 4
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2464
Mailing Address - Country:US
Mailing Address - Phone:731-215-2277
Mailing Address - Fax:731-215-2318
Practice Address - Street 1:1869 HIGHWAY 45 BYP
Practice Address - Street 2:SUITE 4
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2464
Practice Address - Country:US
Practice Address - Phone:731-215-2277
Practice Address - Fax:731-215-2318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10533261QH0100X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1519182Medicaid