Healthcare Provider Details

I. General information

NPI: 1255376083
Provider Name (Legal Business Name): EAST TENNESSEE FOOT CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 10/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 SMITHVIEW DR
MARYVILLE TN
37803-6100
US

IV. Provider business mailing address

603 SMITHVIEW DR
MARYVILLE TN
37803-6100
US

V. Phone/Fax

Practice location:
  • Phone: 865-981-4595
  • Fax: 865-981-4544
Mailing address:
  • Phone: 865-981-4595
  • Fax: 865-981-4544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number641
License Number StateTN

VIII. Authorized Official

Name: DR. LAUREL BURGER COOK
Title or Position: PRESIDENT
Credential: DPM
Phone: 865-981-4595