Healthcare Provider Details

I. General information

NPI: 1649228230
Provider Name (Legal Business Name): MICHAEL PRUMBS LPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 01/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2408 FORT HENRY DR
KINGSPORT TN
37664-3708
US

IV. Provider business mailing address

2408 FORT HENRY DR
KINGSPORT TN
37664-3708
US

V. Phone/Fax

Practice location:
  • Phone: 423-246-7272
  • Fax: 423-246-2803
Mailing address:
  • Phone: 423-246-7272
  • Fax: 423-246-2803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberORT16
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberPRO16
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: