Healthcare Provider Details

I. General information

NPI: 1083190227
Provider Name (Legal Business Name): LAWRENCE WISE H.I.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 WEST AVE STE 101
CROSSVILLE TN
38555-4080
US

IV. Provider business mailing address

119 BIRCHWOOD LN
CROSSVILLE TN
38555-4189
US

V. Phone/Fax

Practice location:
  • Phone: 931-707-9543
  • Fax: 931-707-9543
Mailing address:
  • Phone: 931-709-0661
  • Fax: 931-709-0661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number915
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: