1568894541 NPI number — MRS. CRYSTAL CONSTANCE MCINDOO M.S.

Table of content: MRS. CRYSTAL CONSTANCE MCINDOO M.S. (NPI 1568894541)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568894541 NPI number — MRS. CRYSTAL CONSTANCE MCINDOO M.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCINDOO
Provider First Name:
CRYSTAL
Provider Middle Name:
CONSTANCE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LOZIER
Provider Other First Name:
CRYSTAL
Provider Other Middle Name:
CONSTANCE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1568894541
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6350 W ANDREW JOHNSON HWY
Provider Second Line Business Mailing Address:
DEPARTMENT 100
Provider Business Mailing Address City Name:
TALBOTT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37877-8605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-355-3565
Provider Business Mailing Address Fax Number:
423-714-2355

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7714 CONNER RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
POWELL
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37849-3559
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-947-6220
Provider Business Practice Location Address Fax Number:
865-512-1069
Provider Enumeration Date:
08/01/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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