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General NPI Number Information
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NPI Number | 1124665278
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Entity Type | Organization
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Legal Business Name | SMOKY MOUNTAIN NATURAL WELLNESS
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Dates
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Enumeration Date | 12/09/2019
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Last Update Date | 12/09/2019
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Provider Practice Location Address
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Address Line | 2211 E BROADWAY AVE
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City | MARYVILLE
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State | TN
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Zip | 37804-3078
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Country | US
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Telephone | 865-296-2955
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Fax |
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Provider Business Mailing Address
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Address Line | 2314 TIPTON LOOP RD
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City | MARYVILLE
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State | TN
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Zip | 37803-1855
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Country | US
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Telephone | 865-296-2955
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JORDAN BLAKE BORING
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Credential | L. AC.
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Telephone | 865-296-2955
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number |
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License Number State |
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