=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356432041
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KINGSTON FAMILY PRACTICE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2006
-----------------------------------------------------
Last Update Date | 05/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 820 W RACE ST
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37763-2120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-376-3406
-----------------------------------------------------
Fax | 865-376-9091
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 820 W RACE ST
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37763-2120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-376-3406
-----------------------------------------------------
Fax | 865-376-9091
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DWIGHT H WILLETT
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 865-376-3406
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------