Fast Pace Medical Clinic PLLC
Organization Active NPI Rural Health Clinic/Center · Woodbury, TN
NPI 1154086353 · NPPES record last updated Nov 2, 2021
Key facts
- NPI
- 1154086353
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- FAST PACE MEDICAL CLINIC PLLC
- Practice address
- 829 W Main St
Woodbury, TN 37190-1032 - Phone
- (615) 616-6010
- Fax
- (615) 616-6011
- NPI assigned
- Nov 2, 2021
- Organization subpart
- No
Authorized official
- Name
- Robert Benson
- Title
- Coo
- Phone
- (931) 253-1110
Owners & managing parties with NPI records 3
-
Dana Kay Martin, C.F.N.P.
-
Selena Michelle Gurley, CRNP
Other NPIs on the same Medicare enrollment 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in TN
Rural health clinic certification: CCN 883907
- Legal name
- FAST PACE MEDICAL CLINIC PLLC
- Doing business as
- FAST PACE HEALTH
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Feb 1, 2022
- Last certification
- Feb 1, 2022
- Ownership / control type
- 1A
- Organization structure
- Other · Proprietary
- Incorporated
- Oct 5, 2009 in TN
- Enrollment address
- 829 W Main St
Woodbury, TN 37190-1032
All disclosed owners & managing parties 5
| Name | Role | Since | Share |
|---|---|---|---|
| Selena Michelle Gurley |
5% Or Greater Direct Ownership Interest | Oct 5, 2019 | 33.33% |
| Fpmcm, LLC |
Operational/Managerial Control | Oct 5, 2009 | 100% |
| Sydni Clemmons |
Corporate Director |
Nov 1, 2021 | |
| W-2 Managing Employee | Nov 1, 2021 | ||
| Karen Denise Daingerfield |
5% Or Greater Direct Ownership Interest | Oct 5, 2019 | 33.33% |
| Dana Kay Martin |
5% Or Greater Direct Ownership Interest | Oct 5, 2019 | 33.33% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20220119000923 | TN | Part a Provider - Rural Health Clinic | 5395881841 |
1 other NPI on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Woodbury, TN |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
829 W Main St
Woodbury, TN 37190-1032
Mailing address
PO Box 306244
Nashville, TN 37230-6244
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1515574 | Medicaid | TN |
Other providers in Woodbury, TN
- Doolittle Emergency Physicians LLC
- Victoria Eden Duggin
- Kristina Nicole Eakes
- East Fork Medical Clinic, LLC
- Tevin Evans
- Fast Pace Medical Clinic PLLC
- Generations Health Assoc. Inc., Dba Generations of Woodbury
- Generations Health Association Inc.Dba Generations of Woodbury
- Anna Goodwin
- Helana Maged Grant
All providers in Woodbury, TN · Rural Health Clinic/Center in Tennessee
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 2, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.