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General NPI Number Information
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NPI Number | 1295228666
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Entity Type | Organization
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Legal Business Name | SUSAN C CARNAHAN LAKE BUM DELIVERY
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Dates
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Enumeration Date | 06/11/2018
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Last Update Date | 06/11/2018
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Provider Practice Location Address
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Address Line | 1454 FRANCIS STATION DR
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City | KNOXVILLE
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State | TN
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Zip | 37909-1123
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Country | US
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Telephone | 865-207-7855
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Fax |
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Provider Business Mailing Address
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Address Line | 1454 FRANCIS STATION DR
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City | KNOXVILLE
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State | TN
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Zip | 37909-1123
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Country | US
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Telephone | 865-207-7855
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SUSAN CARNAHAN
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Credential | OT
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Telephone | 865-207-7855
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 1142
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License Number State | TN
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