Healthcare Provider Details

I. General information

NPI: 1316113392
Provider Name (Legal Business Name): RONALD G HENSLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 04/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 GRANDE AVENUE
COPPERHILL TN
37317-0482
US

IV. Provider business mailing address

PO BOX 482
COPPERHILL TN
37317-0482
US

V. Phone/Fax

Practice location:
  • Phone: 423-496-3800
  • Fax:
Mailing address:
  • Phone: 423-496-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126900000X
TaxonomyDental Laboratory Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: