Healthcare Provider Details

I. General information

NPI: 1639472137
Provider Name (Legal Business Name): PIKEVILLE CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2010
Last Update Date: 11/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3062 MAIN ST
PIKEVILLE TN
37367-5746
US

IV. Provider business mailing address

PO BOX 349
PIKEVILLE TN
37367-0349
US

V. Phone/Fax

Practice location:
  • Phone: 423-447-2955
  • Fax: 423-447-2405
Mailing address:
  • Phone: 423-447-2955
  • Fax: 423-447-2405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RUTH E. BOYNTON
Title or Position: MEMBER
Credential: APN
Phone: 423-447-2955