Healthcare Provider Details

I. General information

NPI: 1174662811
Provider Name (Legal Business Name): MERRELL FOOT CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 11/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 THORNTON TAYLOR PKWY SUITE B
FAYETTEVILLE TN
37334-3651
US

IV. Provider business mailing address

PO BOX 327
BELL BUCKLE TN
37020-0327
US

V. Phone/Fax

Practice location:
  • Phone: 931-433-9600
  • Fax: 931-433-9601
Mailing address:
  • Phone: 931-389-9772
  • Fax: 931-389-9772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number492
License Number StateTN

VIII. Authorized Official

Name: MRS. MARNIE LEE MERRELL
Title or Position: PRESIDENT
Credential:
Phone: 931-389-9772