Healthcare Provider Details

I. General information

NPI: 1225352164
Provider Name (Legal Business Name): SALE CREEK FAMILY PRACTICE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2010
Last Update Date: 03/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 GRIFFITH ST
SALE CREEK TN
37373-9715
US

IV. Provider business mailing address

PO BOX 746
CHATTANOOGA TN
37401-0746
US

V. Phone/Fax

Practice location:
  • Phone: 423-332-1813
  • Fax: 423-332-7732
Mailing address:
  • Phone: 423-877-2312
  • Fax: 423-877-5855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1671
License Number StateTN

VIII. Authorized Official

Name: DANIEL T. BLACK
Title or Position: OWNER
Credential: DO
Phone: 423-332-1813