Healthcare Provider Details

I. General information

NPI: 1750049193
Provider Name (Legal Business Name): MABREY R DUFF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3206 KINGSMORE DR
KNOXVILLE TN
37921-1450
US

IV. Provider business mailing address

3206 KINGSMORE DR
KNOXVILLE TN
37921-1450
US

V. Phone/Fax

Practice location:
  • Phone: 865-803-8981
  • Fax: 865-522-3062
Mailing address:
  • Phone: 865-803-8981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: MABREY RAYMOND DUFF
Title or Position: OWNER
Credential:
Phone: 186-580-3898