Healthcare Provider Details

I. General information

NPI: 1679834998
Provider Name (Legal Business Name): UAP CHATTANOOGA PAIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 12/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 EXECUTIVE DR
HIXSON TN
37343-3995
US

IV. Provider business mailing address

1016 EXECUTIVE DR
HIXSON TN
37343-3995
US

V. Phone/Fax

Practice location:
  • Phone: 423-648-4525
  • Fax: 423-648-4626
Mailing address:
  • Phone: 615-376-7550
  • Fax: 615-329-6290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: BRADLEY S. KELLER
Title or Position: OFFICER/AUTHORIZED OFFICIAL
Credential: CRNA
Phone: 423-933-8596