Healthcare Provider Details

I. General information

NPI: 1235239807
Provider Name (Legal Business Name): MR. LARRY WAYNE BERNARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 CAVETTE HILL LN
KNOXVILLE TN
37934-6673
US

IV. Provider business mailing address

7028 CHARTWELL RD
KNOXVILLE TN
37931-2538
US

V. Phone/Fax

Practice location:
  • Phone: 865-777-4000
  • Fax:
Mailing address:
  • Phone: 865-938-0567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number000357
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: