Healthcare Provider Details

I. General information

NPI: 1356234272
Provider Name (Legal Business Name): URBAN RADIANCE MEDICAL SPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2025
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5675 W ANDREW JOHNSON HWY
MORRISTOWN TN
37814-1031
US

IV. Provider business mailing address

5675 W ANDREW JOHNSON HWY
MORRISTOWN TN
37814-1031
US

V. Phone/Fax

Practice location:
  • Phone: 423-839-0710
  • Fax: 689-232-4757
Mailing address:
  • Phone: 423-839-0710
  • Fax: 689-232-4757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: HEATHER A MULLINS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 423-839-0710