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General NPI Number Information
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NPI Number | 1821887944
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Entity Type | Organization
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Legal Business Name | INTERVENTIONAL DIABETES CENTER LLC 4
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Dates
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Enumeration Date | 05/05/2025
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Last Update Date | 09/02/2025
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Provider Practice Location Address
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Address Line | 440 S POPLAR ST
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City | KENTON
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State | TN
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Zip | 38233-3622
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Country | US
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Telephone | 901-791-1711
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Fax |
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Provider Business Mailing Address
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Address Line | 440 S POPLAR ST
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City | KENTON
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State | TN
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Zip | 38233-3622
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MAURICE HAMPTON
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Credential |
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Telephone | 901-791-1711
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number |
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License Number State |
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