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General NPI Number Information
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NPI Number | 1710314513
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Entity Type | Organization
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Legal Business Name | HEART OF TENNESSEE WELLNESS INC.
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Dates
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Enumeration Date | 10/11/2013
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Last Update Date | 10/11/2013
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Provider Practice Location Address
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Address Line | 745 S CHURCH ST SUITE A 130
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City | MURFREESBORO
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State | TN
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Zip | 37130-4984
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Country | US
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Telephone | 931-735-6300
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Fax | 931-735-6302
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Provider Business Mailing Address
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Address Line | 745 S CHURCH ST SUITE A 130
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City | MURFREESBORO
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State | TN
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Zip | 37130-4984
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Country | US
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Telephone | 931-735-6300
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Fax | 931-735-6302
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Authorized Official
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Title or Position | FOUNDER/MEDICAL ADVISOR
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Name | MRS. TINA C GRESHAM
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Credential | M.D.
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Telephone | 931-735-6300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 24607
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License Number State | TN
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