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General NPI Number Information
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NPI Number | 1467992446
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Entity Type | Organization
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Legal Business Name | EASTLAKE MEDICAL, LLC
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Dates
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Enumeration Date | 02/24/2017
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Last Update Date | 09/09/2025
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Provider Practice Location Address
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Address Line | 2205 JACKSBORO PIKE
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City | LA FOLLETTE
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State | TN
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Zip | 37766-2904
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Country | US
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Telephone | 423-352-6500
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Fax |
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Provider Business Mailing Address
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Address Line | 2205 JACKSBORO PIKE
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City | LA FOLLETTE
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State | TN
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Zip | 37766-2904
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Country | US
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Telephone | 423-352-6500
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Fax | 423-352-6501
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | PAULA MADRON
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Credential |
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Telephone | 423-494-9673
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number |
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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