Provider Demographics
NPI:1912171265
Name:PREMIER FAMILY HEALTHCARE
Entity type:Organization
Organization Name:PREMIER FAMILY HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:K
Authorized Official - Last Name:GORE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:931-392-4169
Mailing Address - Street 1:5833 AEDC RD
Mailing Address - Street 2:
Mailing Address - City:ESTILL SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:37330-3915
Mailing Address - Country:US
Mailing Address - Phone:931-392-4169
Mailing Address - Fax:
Practice Address - Street 1:504 N JACKSON ST STE 103
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-3520
Practice Address - Country:US
Practice Address - Phone:931-841-3821
Practice Address - Fax:931-841-3869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN08403171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1510611Medicaid
TN39293821Medicaid
TN4176719OtherBLUE CROSS
TND02233OtherRR MC
TNQ21223Medicare UPIN
TN1510611Medicaid