Healthcare Provider Details

I. General information

NPI: 1750264560
Provider Name (Legal Business Name): 1977 MESK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2025
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 OAKLAND DR NW
CLEVELAND TN
37312-5278
US

IV. Provider business mailing address

2900 OAKLAND DR NW
CLEVELAND TN
37312-5278
US

V. Phone/Fax

Practice location:
  • Phone: 315-569-5318
  • Fax:
Mailing address:
  • Phone: 407-305-3791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: ERICA VALLEE
Title or Position: ADMINISTRATOR
Credential:
Phone: 407-305-3791