Healthcare Provider Details

I. General information

NPI: 1306036769
Provider Name (Legal Business Name): HENDERSONVILLE OBGYN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2007
Last Update Date: 05/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 NEW SHACKLE ISLAND RD SUITE 341-C
HENDERSONVILLE TN
37075-2379
US

IV. Provider business mailing address

353 NEW SHACKLE ISLAND RD SUITE 341-C
HENDERSONVILLE TN
37075-2379
US

V. Phone/Fax

Practice location:
  • Phone: 615-826-1716
  • Fax: 615-826-4841
Mailing address:
  • Phone: 615-826-1716
  • Fax: 615-826-4841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHUCK LOCKE
Title or Position: VICE PRESIDENT
Credential:
Phone: 615-373-7604