Healthcare Provider Details

I. General information

NPI: 1477747293
Provider Name (Legal Business Name): MCKENZIE MEDICAL CENTER LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 HOSPITAL DR SUITE A
MC KENZIE TN
38201-1649
US

IV. Provider business mailing address

205 HOSPITAL DR SUITE A
MC KENZIE TN
38201-1649
US

V. Phone/Fax

Practice location:
  • Phone: 731-352-7907
  • Fax: 731-352-4459
Mailing address:
  • Phone: 731-352-7907
  • Fax: 731-352-4459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD23833
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberMD23833
License Number StateTN

VIII. Authorized Official

Name: MRS. LISA K PAGE
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 731-352-7907