Provider Demographics
NPI:1174872139
Name:METHODIST LE BONHEUR COMMUNITY OUTREACH
Entity type:Organization
Organization Name:METHODIST LE BONHEUR COMMUNITY OUTREACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:BURNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-984-9963
Mailing Address - Street 1:1535 VANN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2095
Mailing Address - Country:US
Mailing Address - Phone:731-499-0977
Mailing Address - Fax:731-499-9939
Practice Address - Street 1:77 STONEBRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2165
Practice Address - Country:US
Practice Address - Phone:901-287-5961
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-06
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity HealthGroup - Multi-Specialty