Healthcare Provider Details

I. General information

NPI: 1659648764
Provider Name (Legal Business Name): HOT ROD SHANNON, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2011
Last Update Date: 11/18/2011
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

2303 MORGAN COUNTY HWY
WARTBURG TN
37887-3528
US

V. Phone/Fax

Practice location:
  • Phone: 423-346-4630
  • Fax: 423-346-4631
Mailing address:
  • Phone: 423-346-4630
  • Fax: 423-346-4631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ALICE FREELS
Title or Position: PRESIDENT
Credential:
Phone: 423-539-2757