Healthcare Provider Details

I. General information

NPI: 1285079558
Provider Name (Legal Business Name): EXPERIENCED CARE CLINIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 09/11/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8008 MAIN ST
POUND VA
24279-0000
US

IV. Provider business mailing address

PO BOX 908
POUND VA
24279-0908
US

V. Phone/Fax

Practice location:
  • Phone: 276-796-4586
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. TAMMY BRANHAM
Title or Position: OWNER
Credential: FNP
Phone: 276-393-8284