Coffee Medical Group LLC
Organization Active NPI Rural Health Clinic/Center · Manchester, TN
NPI 1700192028 · NPPES record last updated Feb 9, 2024
Key facts
- NPI
- 1700192028
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- License
- 19 (TN)
- Legal business name
- COFFEE MEDICAL GROUP LLC
- Practice address
- 1615 McMinnville Hwy
Manchester, TN 37355-3179 - Phone
- (931) 728-6205
- Fax
- (931) 723-3194
- NPI assigned
- Aug 24, 2010
- Organization subpart
- No
Authorized official
- Name
- Mr. Robert J Couch
- Title
- Ceo
- Phone
- (931) 728-6354
Other NPIs on the same Medicare enrollment 2
Other NPIs with the same Medicare PAC ID 3
Corporate family (same tax ID) 7
Related certifications (CCN) 1
Facilities with the same owner 3
Practitioners 120
-
William D Daniel, DO
-
Amy J Bass, N P
-
Nicole Lynn Brinkley, FNP
-
Charles S. Drummond III, M.D.
-
Regina Eyo, APRN
-
Amy Brock Fleming, APN
-
George Holburn, ANP
-
Kellie Humphrey, NP-C
-
Lacey L Jones, FNP
-
Laura N Kimball, NP
-
Sherry Kinkade, FNP
-
Holly Anne Liter, APN, RN
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 44D0309672 | Coffee Medical Group LLC | Certificate of waiver | Jan 16, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in TN
Rural health clinic certification: CCN 443450
- Legal name
- COFFEE MEDICAL GROUP LLC
- Doing business as
- CENTER FOR FAMILY MEDICINE
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Jul 1, 2015
- Last certification
- Nov 1, 2016
- Ownership / control type
- 1B
- Organization structure
- LLC · Non-profit
- Incorporated
- Jun 7, 2002 in TN
- Enrollment address
- 1615 McMinnville Hwy
Manchester, TN 37355-3179 - Related CCNs
- 440007
All disclosed owners & managing parties 6
| Name | Role | Since | Share |
|---|---|---|---|
| Unity Medical Center Inc |
5% Or Greater Direct Ownership Interest | Jul 15, 2019 | 100% |
| Martha McCormick |
Corporate Officer |
Jan 1, 2013 | 35% |
| Amy Freeze |
W-2 Managing Employee |
Jul 1, 2015 | 10% |
| Doug McAbee |
Corporate Officer |
Feb 1, 2024 | 5% |
| Medical Associates Development LLC |
5% Or Greater Security Interest | Jul 1, 2015 | 32% |
| Servisfirst Bank |
5% Or Greater Security Interest | Jul 15, 2019 | 56% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20120322000701 | TN | Part B Supplier - Clinic/Group Practice | 1456317783 |
Receives reassigned benefits from 3 practitioners 2 other NPIs on this enrollment Practice locations: Manchester, TN |
| O20160125000433 | TN | Part a Provider - Rural Health Clinic | 1850208794 | Practice locations: Manchester, TN |
National Provider Directory
- Tax ID family
- Coffee Medical Group LLC
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | 19 | TN | Yes |
Addresses
Primary practice location
1615 McMinnville Hwy
Manchester, TN 37355-3179
Mailing address
1615 McMinnville Hwy
Manchester, TN 37355-3179
Phone (931) 728-6205
Other names
- CENTER FOR FAMILY MEDICINE
Other providers in Manchester, TN
- Coffee Medical Group LLC
- Coffee Medical Group LLC
- Coffee Medical Group LLC
- Coffee Medical Group LLC
- Coffee Medical Group LLC
- Coffee Medical Group LLC
- Stephania Rose Colangione
- Connecting Helpers LLC
- Lana Branum Cook
- Thomas Daniel Cosby
All providers in Manchester, 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 Feb 9, 2024. 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.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.