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General NPI Number Information
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NPI Number | 1932750189
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Entity Type | Organization
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Legal Business Name | ETLOG MANAGEMENT SERVICE
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Dates
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Enumeration Date | 09/27/2019
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Last Update Date | 09/08/2020
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Provider Practice Location Address
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Address Line | 1005 CARRINGTON CT
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City | KINGSPORT
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State | TN
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Zip | 37660-5694
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Country | US
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Telephone | 423-677-7040
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Fax |
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Provider Business Mailing Address
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Address Line | 1005 CARRINGTON CT
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City | KINGSPORT
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State | TN
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Zip | 37660-5694
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Country | US
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Telephone | 423-677-7040
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. YAW OTCHERE-BOATENG
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Credential | MD
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Telephone | 423-677-7040
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QV0200X
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Taxonomy Name | VA Clinic/Center
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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 | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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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 | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 261QR0208X
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Taxonomy Name | Mobile Radiology Clinic/Center
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #9
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #10
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Taxonomy Code | 3245S0500X
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Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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Taxonomy #11
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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