Healthcare Provider Details

I. General information

NPI: 1235140385
Provider Name (Legal Business Name): ENDOSCOPY CENTER OF KINGSPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 PAVILION DR STE 108
KINGSPORT TN
37660-4651
US

IV. Provider business mailing address

2204 PAVILION DR SUITE 108
KINGSPORT TN
37660-4657
US

V. Phone/Fax

Practice location:
  • Phone: 423-392-6100
  • Fax: 423-392-6159
Mailing address:
  • Phone: 423-392-6100
  • Fax: 423-392-6159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number0000000053
License Number StateTN

VIII. Authorized Official

Name: MS. PENNY LEIGH LLOYD
Title or Position: ADMINISTRATOR
Credential:
Phone: 423-392-6100