Healthcare Provider Details

I. General information

NPI: 1073668653
Provider Name (Legal Business Name): ORANGE GROVE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 03/04/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 DERBY ST
CHATTANOOGA TN
37404-1632
US

IV. Provider business mailing address

615 DERBY ST ATTENTION: HEALTH INFORMATICS & REIMBURSEMENT
CHATTANOOGA TN
37404-1632
US

V. Phone/Fax

Practice location:
  • Phone: 423-493-2905
  • Fax: 423-493-2950
Mailing address:
  • Phone: 423-493-2906
  • Fax: 423-493-2950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number13774
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8686
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number26723
License Number StateTN

VIII. Authorized Official

Name: MS. TERA ROBERTS
Title or Position: CEO
Credential:
Phone: 423-493-2910