Healthcare Provider Details

I. General information

NPI: 1255594487
Provider Name (Legal Business Name): BEAN STATION FAMILY MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 07/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1179 HIGHWAY 11W
BEAN STATION TN
37708-5809
US

IV. Provider business mailing address

PO BOX 455
BEAN STATION TN
37708-0455
US

V. Phone/Fax

Practice location:
  • Phone: 865-993-1070
  • Fax: 865-993-1075
Mailing address:
  • Phone: 865-993-1070
  • Fax: 865-993-1075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. HECTOR L VEGA
Title or Position: OWNER
Credential: PA-C
Phone: 865-993-1070