=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063180750
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OKIES CLINICAL SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2021
-----------------------------------------------------
Last Update Date | 09/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1050 RUTLEDGE PIKE
-----------------------------------------------------
City | BLAINE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37709-3027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-200-6966
-----------------------------------------------------
Fax | 865-932-7775
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1050 RUTLEDGE PIKE
-----------------------------------------------------
City | BLAINE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37709-3027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-200-6966
-----------------------------------------------------
Fax | 865-932-7775
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | MICAH CRAINE
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 423-200-6966
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------