Healthcare Provider Details

I. General information

NPI: 1881452928
Provider Name (Legal Business Name): CHARLES ELDER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2024
Last Update Date: 03/28/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4405 OAKBANK LN
KNOXVILLE TN
37921-5247
US

IV. Provider business mailing address

4405 OAKBANK LN
KNOXVILLE TN
37921-5247
US

V. Phone/Fax

Practice location:
  • Phone: 865-247-3285
  • Fax:
Mailing address:
  • Phone: 865-247-3285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number098683259
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number098683259
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: