Healthcare Provider Details

I. General information

NPI: 1518105683
Provider Name (Legal Business Name): DAVID FOX TALLEY RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2009
Last Update Date: 09/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W STONE DR STE 2D
KINGSPORT TN
37660-3256
US

IV. Provider business mailing address

PO BOX 9
KINGSPORT TN
37662-0009
US

V. Phone/Fax

Practice location:
  • Phone: 423-578-1588
  • Fax:
Mailing address:
  • Phone: 423-857-2066
  • Fax: 423-857-2030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2064
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: