=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528762671
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOULEVARD ENT SURGERY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2023
-----------------------------------------------------
Last Update Date | 03/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9300 PARK WEST BLVD
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37923-4301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-427-4040
-----------------------------------------------------
Fax | 865-427-4041
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9300 PARK WEST BLVD
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37923-4301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-427-4040
-----------------------------------------------------
Fax | 865-427-4041
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE DIRECTOR
-----------------------------------------------------
Name | JANELLE L JOHNSON
-----------------------------------------------------
Credential | RN, BSN
-----------------------------------------------------
Telephone | 865-427-4040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------