Healthcare Provider Details

I. General information

NPI: 1265687917
Provider Name (Legal Business Name): CHATTANOOGA FAMILY AND SPORTS MEDICAL CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2008
Last Update Date: 11/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6035 SHALLOWFORD RD SUITE 101
CHATTANOOGA TN
37421-1688
US

IV. Provider business mailing address

6035 SHALLOWFORD RD SUITE 101
CHATTANOOGA TN
37421-1688
US

V. Phone/Fax

Practice location:
  • Phone: 423-499-0003
  • Fax:
Mailing address:
  • Phone: 423-499-0003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number1241
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number1789
License Number StateTN

VIII. Authorized Official

Name: DR. JEFFERY G HALL
Title or Position: MEMBER
Credential: DC
Phone: 423-499-0003