Facts
- Status
- A
- Type
- Individual
- Enumeration date
- 2014-08-01
- Last updated
- 2014-08-01
Specialties
Licenses
- License TN
- 165752
Location
- Practice location
- 389 RIVER RD
- City
- DECATUR TN
- Postal code
- 373227801
- Phone
- 423-334-5185
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.