Active NPI
Fast Pace Medical Clinic PLLC
- Rural Health Clinic/Center
- Lawrenceburg, TN
National Provider Identifier
1417612789
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Rural Health Clinic/Center
- Legal business name
- FAST PACE MEDICAL CLINIC PLLC
- Practice address
- 129 N Locust Ave
Lawrenceburg, TN 38464-3757 - Phone
- (931) 762-7232
- Fax
- (931) 762-7234
- NPI assigned
- Nov 2, 2021
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Robert Benson
- Title
- Coo
- Phone
- (931) 253-1110
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Primary |
Addresses
Primary practice location
129 N Locust Ave
Lawrenceburg, TN 38464-3757
Mailing address
PO Box 306244
Nashville, TN 37230-6244
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1515574 | Medicaid | TN |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in TN
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20211130000619 | 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: Lawrenceburg, TN |
Rural health clinic certification: CCN 883862
- 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
- Incorporated
- Oct 5, 2009 in TN
- Enrollment address
- 129 N Locust Ave
Lawrenceburg, TN 38464-3757
Other NPIs on the same Medicare enrollment 1
NPIs listed together on one Medicare enrollment, typically parts of the same organization.
-
- Rural Health Clinic/Center
- Chapel Hill, TN
- NPI 1316602774
O20211130000619
National Provider Directory
National Provider DirectoryOwnership & related parties
All disclosed owners & managing parties 5
As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.
| Name | Role | Since | Share |
|---|---|---|---|
| Selena Michelle Gurley | 5% Or Greater Direct Ownership Interest | May 1, 2019 | 33.33% |
| Sydni Clemmons | Corporate Director | Nov 1, 2021 | |
| W-2 Managing Employee | Nov 1, 2021 | ||
| Karen Denise Daingerfield | 5% Or Greater Direct Ownership Interest | May 1, 2019 | 33.33% |
| Fpmcm, LLC | Operational/Managerial Control | Oct 5, 2009 | 100% |
| Dana Kay Martin | 5% Or Greater Direct Ownership Interest | May 1, 2019 | 33.33% |
Owners & managing parties with NPI records 3
Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.
-
- Family Nurse Practitioner
- McMinnville, TN
- NPI 1538594494
5% Or Greater Direct Ownership Interest
-
- Family Nurse Practitioner
- Selmer, TN
- NPI 1497781454
5% Or Greater Direct Ownership Interest
-
- Family Nurse Practitioner
- Florence, AL
- NPI 1215214432
5% Or Greater Direct Ownership Interest
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1635811200000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1635811200000",
"number": "1417612789",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 306244",
"city": "NASHVILLE",
"state": "TN",
"postal_code": "372306244"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "129 N LOCUST AVE",
"city": "LAWRENCEBURG",
"state": "TN",
"postal_code": "384643757",
"telephone_number": "931-762-7232",
"fax_number": "931-762-7234"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "FAST PACE MEDICAL CLINIC PLLC",
"organizational_subpart": "NO",
"enumeration_date": "2021-11-02",
"last_updated": "2021-11-02",
"certification_date": "2021-11-02",
"status": "A",
"authorized_official_last_name": "BENSON",
"authorized_official_first_name": "ROBERT",
"authorized_official_title_or_position": "COO",
"authorized_official_telephone_number": "931-253-1110"
},
"taxonomies": [
{
"code": "261QR1300X",
"taxonomy_group": "",
"desc": "Clinic/Center, Rural Health",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1515574",
"state": "TN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Lawrenceburg, TN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 2, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.