Healthcare Provider Details

I. General information

NPI: 1861844763
Provider Name (Legal Business Name): FAMILY AND PEDIATRIC CARE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19067 ALBERTA ST
ONEIDA TN
37841-6002
US

IV. Provider business mailing address

PO BOX 681
SYLVA NC
28779-0681
US

V. Phone/Fax

Practice location:
  • Phone: 423-569-2754
  • Fax: 423-569-2756
Mailing address:
  • Phone: 828-339-7253
  • Fax: 828-586-8209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0000016521
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0000020552
License Number StateTN

VIII. Authorized Official

Name: MRS. DONNA WEST
Title or Position: OFFICE MANAGER
Credential:
Phone: 423-569-2754