Healthcare Provider Details

I. General information

NPI: 1053719708
Provider Name (Legal Business Name): MOUNTAIN MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2014
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3614 UNICOI DR
UNICOI TN
37692-6860
US

IV. Provider business mailing address

3614 UNICOI DR
UNICOI TN
37692-6860
US

V. Phone/Fax

Practice location:
  • Phone: 276-270-2145
  • Fax: 276-270-2146
Mailing address:
  • Phone: 276-270-2145
  • Fax: 276-270-2146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2208
License Number StateTN

VIII. Authorized Official

Name: CYNTHIA REECE
Title or Position: OWNER
Credential:
Phone: 423-270-2145