| Organization Name: | PROVIDENCE MEDICAL CLINIC LLC |
| NPI Number: | 1124215405 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | RANDY E FLORENDO (OWNER / PROVIDER) |
| Mailing Address: | 2354 Highway 41 S Greenbrier |
| State: | TN US |
| Postal Code: | 370735510 |
| Phone Number: | 6154836675 |
| Fax Number: | |
| NPI Enumeration Date: | 10/01/2007 |
| NPI Last Update Date: | 04/29/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 174400000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Specialist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |