=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770080632
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST TENNESSEE ADDICTION SPECIALISTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2018
-----------------------------------------------------
Last Update Date | 01/08/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 STATION DR BLDG 3
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37804-4190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-268-4360
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 STATION DR BLDG 3
-----------------------------------------------------
City | MARYVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37804-4190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-268-4360
-----------------------------------------------------
Fax | 865-329-6507
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COOWNER
-----------------------------------------------------
Name | CLAY EUGENE STALCUP
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 865-406-2715
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------