Healthcare Provider Details

I. General information

NPI: 1689047375
Provider Name (Legal Business Name): HOT ROD SHANNON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2015
Last Update Date: 11/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2303 MORGAN COUNTY HWY
WARTBURG TN
37887-3528
US

IV. Provider business mailing address

PO BOX 1057 117 COON HUNTER ROAD
WARTBURG TN
37887-1057
US

V. Phone/Fax

Practice location:
  • Phone: 865-748-7003
  • Fax: 423-346-2139
Mailing address:
  • Phone: 865-748-7003
  • Fax: 423-346-2139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES THOMAS CAMPBELL
Title or Position: PRESIDENT
Credential:
Phone: 865-748-7003