Healthcare Provider Details

I. General information

NPI: 1790612323
Provider Name (Legal Business Name): SOUTHERN ORTHOCARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 PRINCETON RD STE 1
JOHNSON CITY TN
37601-2040
US

IV. Provider business mailing address

403 PRINCETON RD STE 1
JOHNSON CITY TN
37601-2040
US

V. Phone/Fax

Practice location:
  • Phone: 423-430-9480
  • Fax: 423-430-9480
Mailing address:
  • Phone: 423-430-9480
  • Fax: 423-430-9480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: SHEENA E WILLIAMS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 423-307-1890