Provider Demographics
NPI:1063876076
Name:PETRE-JO LLC
Entity type:Organization
Organization Name:PETRE-JO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:KONECNY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-761-0410
Mailing Address - Street 1:858 HARBOUR GREENS PL
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:TN
Mailing Address - Zip Code:38583-4294
Mailing Address - Country:US
Mailing Address - Phone:931-761-0410
Mailing Address - Fax:855-210-7700
Practice Address - Street 1:607 W DUE WEST AVE STE 95
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-4415
Practice Address - Country:US
Practice Address - Phone:615-982-8081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PETRE-JO LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-06
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL000000017166305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization