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General NPI Number Information
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NPI Number | 1578000410
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Entity Type | Organization
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Legal Business Name | 1 TEAM CLINIC LLC
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Dates
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Enumeration Date | 01/31/2017
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Last Update Date | 01/31/2017
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Provider Practice Location Address
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Address Line | 199 POTTERTOWN RD
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City | MIDWAY
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State | TN
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Zip | 37809-3213
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Country | US
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Telephone | 423-422-4454
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 416
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City | GREENEVILLE
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State | TN
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Zip | 37744-0416
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Country | US
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Telephone | 423-639-0187
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Fax | 423-639-2504
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. CHARLES CALVIN DOTY JR.
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Credential |
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Telephone | 423-639-0187
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 1043217352
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License Number State | TN
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