Healthcare Provider Details

I. General information

NPI: 1689148686
Provider Name (Legal Business Name): SULACK HEALTH & WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2019
Last Update Date: 01/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 E EMORY RD STE 103
KNOXVILLE TN
37938-4685
US

IV. Provider business mailing address

713 E EMORY RD STE 103
KNOXVILLE TN
37938-4685
US

V. Phone/Fax

Practice location:
  • Phone: 865-938-1070
  • Fax: 865-938-1071
Mailing address:
  • Phone: 865-938-1070
  • Fax: 865-938-1071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY CHAVEZ
Title or Position: PRACTICE CONSULTANT
Credential:
Phone: 865-927-6372