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General NPI Number Information
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NPI Number | 1205356813
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Entity Type | Organization
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Legal Business Name | ELK VALLEY MEDICAL CLINIC, LLC
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Dates
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Enumeration Date | 06/23/2017
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Last Update Date | 01/23/2018
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Provider Practice Location Address
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Address Line | 305 COLLEGE ST W
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City | FAYETTEVILLE
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State | TN
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Zip | 37334-2911
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Country | US
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Telephone | 931-619-3243
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Fax | 888-696-1054
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Provider Business Mailing Address
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Address Line | 305 COLLEGE ST W
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City | FAYETTEVILLE
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State | TN
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Zip | 37334-2911
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Country | US
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Telephone | 931-297-4525
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Fax | 888-696-1054
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Authorized Official
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Title or Position | OWNER / PRACTICE MANAGER
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Name | KARISSA LEE KRISHNAN
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Credential |
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Telephone | 931-619-3243
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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