Healthcare Provider Details

I. General information

NPI: 1073095154
Provider Name (Legal Business Name): CLASS 'A' CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2018
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 W HIGHWAY 25 70 STE D
NEWPORT TN
37821-8045
US

IV. Provider business mailing address

833 W HIGHWAY 25 70 STE D
NEWPORT TN
37821-8045
US

V. Phone/Fax

Practice location:
  • Phone: 423-720-9111
  • Fax: 423-301-5756
Mailing address:
  • Phone: 423-720-9111
  • Fax: 423-301-5756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number16835
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHARLENE CROWDER MATTHEWS
Title or Position: PRACTITIONER
Credential: APN-BC
Phone: 423-720-9111