=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366581654
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEVELAND BACK & NECK CLINIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 06/27/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 MOUSE CREEK RD NW
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37312-4840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-479-8989
-----------------------------------------------------
Fax | 423-478-8992
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3604
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37320-3604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-478-8989
-----------------------------------------------------
Fax | 423-478-8992
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ANGELA FREE MCPHERSON
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 423-478-8989
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------