1730668575 NPI number — KINGSPORT FAMILY MEDICAL CARE PLLC

Table of content: (NPI 1730668575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730668575 NPI number — KINGSPORT FAMILY MEDICAL CARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KINGSPORT FAMILY MEDICAL CARE PLLC
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:
1730668575
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
217 E SPRINGBROOK DR STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37601-1733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-434-2080
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
935 WILCOX CT STE 115
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-5170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-444-9801
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/13/2018

Additional Information

Authorized Official

Authorized Official Last Name:
CHRISTIANSEN
Authorized Official First Name:
CHRISTINA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
423-715-6588

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com