Healthcare Provider Details

I. General information

NPI: 1881483733
Provider Name (Legal Business Name): INTERVENTIONAL DIABETES CENTER LLC 3
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2025
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5362 ESTATE OFFICE DR STE 1
MEMPHIS TN
38119-3630
US

IV. Provider business mailing address

5362 ESTATE OFFICE DR STE 1
MEMPHIS TN
38119-3630
US

V. Phone/Fax

Practice location:
  • Phone: 901-791-1711
  • Fax:
Mailing address:
  • Phone: 901-791-1711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MAURICE HAMPTON
Title or Position: OWNER
Credential:
Phone: 901-791-1711