Healthcare Provider Details

I. General information

NPI: 1114462215
Provider Name (Legal Business Name): EAST TENNESSEE RECOVERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2016
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2408 SUSANNAH ST STE 1
JOHNSON CITY TN
37601-1765
US

IV. Provider business mailing address

2408 SUSANNAH ST STE 1
JOHNSON CITY TN
37601-1765
US

V. Phone/Fax

Practice location:
  • Phone: 423-434-6677
  • Fax: 423-461-0000
Mailing address:
  • Phone: 423-434-6677
  • Fax: 423-461-0000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DANIEL TACKLING
Title or Position: CFO
Credential:
Phone: 423-434-6677