Provider Demographics
NPI:1043537046
Name:COFFEE MEDICAL GROUP LLC
Entity type:Organization
Organization Name:COFFEE MEDICAL GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:COUCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-728-6354
Mailing Address - Street 1:482 INTERSTATE DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-3109
Mailing Address - Country:US
Mailing Address - Phone:931-728-4718
Mailing Address - Fax:931-728-1016
Practice Address - Street 1:482 INTERSTATE DR
Practice Address - Street 2:SUITE A
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-3109
Practice Address - Country:US
Practice Address - Phone:931-728-4718
Practice Address - Fax:931-728-1016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-29
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health