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General NPI Number Information
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NPI Number | 1962779645
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Entity Type | Organization
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Legal Business Name | THE FATIGUE CLINIC LLC
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Dates
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Enumeration Date | 11/22/2011
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Last Update Date | 08/13/2020
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Provider Practice Location Address
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Address Line | 890 W POPLAR AVE STE 6
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City | COLLIERVILLE
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State | TN
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Zip | 38017-2582
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Country | US
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Telephone | 901-221-8621
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Fax | 901-221-8631
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Provider Business Mailing Address
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Address Line | 890 W POPLAR AVE STE 6
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City | COLLIERVILLE
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State | TN
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Zip | 38017-2582
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Country | US
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Telephone | 901-221-8621
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Fax | 901-221-8631
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | SUSAN D EARL
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Credential | ACNP
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Telephone | 901-221-8621
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 12687
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License Number State | TN
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