Healthcare Provider Details

I. General information

NPI: 1881880854
Provider Name (Legal Business Name): COLLEGE PARK WALK-IN CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2007
Last Update Date: 09/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 E ANDREW JOHNSON HWY
MORRISTOWN TN
37814-5412
US

IV. Provider business mailing address

2104 E ANDREW JOHNSON HWY
MORRISTOWN TN
37814-5412
US

V. Phone/Fax

Practice location:
  • Phone: 423-307-1900
  • Fax: 423-307-1902
Mailing address:
  • Phone: 423-307-1900
  • Fax: 423-307-1902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberMD0000029767
License Number StateTN

VIII. Authorized Official

Name: FREDERICK R YARID
Title or Position: OWNER
Credential:
Phone: 423-307-1900