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General NPI Number Information
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NPI Number | 1730101734
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Entity Type | Organization
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Legal Business Name | MARYVILLE FOOT CLINIC INC
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Dates
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Enumeration Date | 07/25/2006
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | 1515 E LAMAR ALEXANDER PKWY
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City | MARYVILLE
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State | TN
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Zip | 37804-5131
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Country | US
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Telephone | 865-982-2119
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Fax | 865-984-5642
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Provider Business Mailing Address
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Address Line | 1515 E LAMAR ALEXANDER PKWY
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City | MARYVILLE
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State | TN
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Zip | 37804-5131
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Country | US
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Telephone | 865-982-2119
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Fax | 865-984-5642
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. BRANDI C HEGERTY
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Credential |
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Telephone | 865-681-6667
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213EP1101X
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Taxonomy Name | Primary Podiatric Medicine Podiatrist
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License Number | 564
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License Number State | TN
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