Healthcare Provider Details

I. General information

NPI: 1467992446
Provider Name (Legal Business Name): EASTLAKE MEDICAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 JACKSBORO PIKE
LA FOLLETTE TN
37766-2904
US

IV. Provider business mailing address

2205 JACKSBORO PIKE
LA FOLLETTE TN
37766-2904
US

V. Phone/Fax

Practice location:
  • Phone: 423-352-6500
  • Fax:
Mailing address:
  • Phone: 423-352-6500
  • Fax: 423-352-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateTN

VIII. Authorized Official

Name: PAULA MICHELLE MADRON
Title or Position: PRACTICE ADMIN
Credential:
Phone: 423-352-6500