Healthcare Provider Details

I. General information

NPI: 1447182886
Provider Name (Legal Business Name): CHARLESTON GRANT MCCORMICK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 HAMPTON CREEK RD
ROAN MOUNTAIN TN
37687-5216
US

IV. Provider business mailing address

244 HAMPTON CREEK RD
ROAN MOUNTAIN TN
37687-5216
US

V. Phone/Fax

Practice location:
  • Phone: 540-354-2862
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: