1063433704 NPI number — SPRING CITY WALK IN MEDICAL CENTER, LLC

Table of content: (NPI 1063433704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063433704 NPI number — SPRING CITY WALK IN MEDICAL CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPRING CITY WALK IN MEDICAL CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063433704
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 709
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRING CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37381-0709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-452-9980
Provider Business Mailing Address Fax Number:
423-452-9980

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
126 LAVENDER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRING CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37381-5102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-452-9984
Provider Business Practice Location Address Fax Number:
423-452-9980
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
DORIS
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
423-452-9984

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  44-3943 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 443943 . This is a "RURAL HEALTH CLINIC" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com