MEDICARE: 1 TEAM CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	1043217352	TN

General Provider Information

NPI Number	:	1578000410
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1 TEAM CLINIC LLC

Provider Business Mailing Address
First Line	:	PO BOX 416
Second Line	:
City	:	GREENEVILLE
State	:	TN
Zip	:	37744-0416
Country	:	US
Telephone Number	:	423-639-0187
Fax Number	:	423-639-2504

Provider Business Practice Location Address
First Line	:	199 POTTERTOWN RD
Second Line	:
City	:	MIDWAY
State	:	TN
Zip	:	37809-3213
Country	:	US
Telephone Number	:	423-422-4454
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. CHARLES CALVIN DOTY JR.
Credential	:
Telephone Number	:	423-639-0187

Provider Enumeration Date	:	01/31/2017
Last Update Date	:	01/31/2017

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