Healthcare Provider Details

I. General information

NPI: 1033747266
Provider Name (Legal Business Name): ASHTYN GORE H.I.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 04/01/2020
Certification Date: 04/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2130 N CHARLES G SEIVERS BLVD STE 2
CLINTON TN
37716-6705
US

IV. Provider business mailing address

2130 N CHARLES G SEIVERS BLVD STE 2
CLINTON TN
37716-6705
US

V. Phone/Fax

Practice location:
  • Phone: 865-392-1430
  • Fax:
Mailing address:
  • Phone: 865-392-1430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number959
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: