=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851523641
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW HORIZONS CONTINENCE MANAGEMENT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2009
-----------------------------------------------------
Last Update Date | 08/13/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2521 BEECHWOOD DR
-----------------------------------------------------
City | ELIZABETHTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37643-5062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-612-0654
-----------------------------------------------------
Fax | 423-543-5323
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2521 BEECHWOOD DR
-----------------------------------------------------
City | ELIZABETHTON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37643-5062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-612-0654
-----------------------------------------------------
Fax | 423-543-5323
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DRIECTOR
-----------------------------------------------------
Name | DR. BRENT DAVID LAING
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 423-542-3802
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 15696
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------