=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710425368
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 1 TEAM LLC TAZEWELL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2017
-----------------------------------------------------
Last Update Date | 02/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 HESTER LN
-----------------------------------------------------
City | TAZEWELL
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37879-5088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-851-1149
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 416
-----------------------------------------------------
City | GREENEVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37744-0416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-639-0187
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. CHARLES C. DOTY JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-639-0187
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1366442782
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------