Healthcare Provider Details

I. General information

NPI: 1578881132
Provider Name (Legal Business Name): LOUDON COUNTY PEDIATRICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2010
Last Update Date: 05/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

423 MEDICAL PARK DR
LENOIR CITY TN
37772-5640
US

IV. Provider business mailing address

423 MEDICAL PARK DR
LENOIR CITY TN
37772-5640
US

V. Phone/Fax

Practice location:
  • Phone: 865-986-9233
  • Fax: 865-986-0148
Mailing address:
  • Phone: 865-986-9233
  • Fax: 865-986-0148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0200X
TaxonomyPediatric Clinical Nurse Specialist
License Number145961
License Number StateTN

VIII. Authorized Official

Name: DWIGHT DANIEL BIVENS
Title or Position: SECRETARY/TREASURER
Credential:
Phone: 865-986-9233