Facts
- Status
- A
- Credential
- EdS
- Type
- Individual
- Enumeration date
- 2005-07-26
- Last updated
- 2026-07-13
Specialties
Licenses
- License TN
- PE11774
Location
- Practice location
- 204 W HOGAN ST
- City
- TULLAHOMA TN
- Postal code
- 373883338
- Phone
- 931-393-1043
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.