1174662811 NPI number — MERRELL FOOT CLINIC PC

Table of content: (NPI 1174662811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174662811 NPI number — MERRELL FOOT CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERRELL FOOT CLINIC PC
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:
1174662811
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 327
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELL BUCKLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37020-0327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-389-9772
Provider Business Mailing Address Fax Number:
931-389-9772

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2250 THORNTON TAYLOR PKWY
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37334-3651
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-433-9600
Provider Business Practice Location Address Fax Number:
931-433-9601
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MERRELL
Authorized Official First Name:
MARNIE
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
931-389-9772

Provider Taxonomy Codes

  • Taxonomy code: 213ES0131X , with the licence number:  492 , 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)





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