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General NPI Number Information
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NPI Number | 1275995623
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Entity Type | Organization
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Legal Business Name | DOMINION MARYVILLE,LLC
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Dates
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Enumeration Date | 03/24/2016
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Last Update Date | 03/24/2016
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Provider Practice Location Address
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Address Line | 2317 US HIGHWAY 411 S
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City | MARYVILLE
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State | TN
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Zip | 37801-8634
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Country | US
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Telephone | 865-238-5338
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Fax |
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Provider Business Mailing Address
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Address Line | 2317 US HIGHWAY 411 S
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City | MARYVILLE
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State | TN
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Zip | 37801-8634
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Country | US
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Telephone | 865-238-5338
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. FRED WHEELER
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Credential |
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Telephone | 865-238-5338
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 423
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License Number State | TN
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