1467992446 NPI number — EASTLAKE MEDICAL, LLC

Table of content: (NPI 1467992446)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467992446 NPI number — EASTLAKE MEDICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTLAKE MEDICAL, 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:
EASTLAKE URGENT CARE
Provider Other Organization Name Type Code:
3
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:
1467992446
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 JACKSBORO PIKE
Provider Second Line Business Mailing Address:
SUITE 6
Provider Business Mailing Address City Name:
JACKSBORO
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37757
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-352-6500
Provider Business Mailing Address Fax Number:
423-352-6501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 JACKSBORO PIKE STE 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSBORO
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37757-2818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-352-6500
Provider Business Practice Location Address Fax Number:
423-352-6501
Provider Enumeration Date:
02/24/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MIESEL
Authorized Official First Name:
VALERIE
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
423-352-6500

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X , 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: Q028641 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6065731 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




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