Healthcare Provider Details

I. General information

NPI: 1720252554
Provider Name (Legal Business Name): EAST TENNESSEE STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 CHRISTIAN CHURCH RD
GRAY TN
37615-4500
US

IV. Provider business mailing address

PO BOX 70403
JOHNSON CITY TN
37614-1703
US

V. Phone/Fax

Practice location:
  • Phone: 423-439-4355
  • Fax:
Mailing address:
  • Phone: 423-439-4078
  • Fax: 423-439-4060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: DAVID D. COLLINS
Title or Position: CFO, VP FINANCE & ADMINISTRATION
Credential:
Phone: 423-439-5884