MEDICARE: TRI CITIES MEN'S HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	85103	TN

General Provider Information

NPI Number	:	1518393818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI CITIES MEN'S HEALTH

Provider Business Mailing Address
First Line	:	154 W SPRINGBROOK DR
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-1758
Country	:	US
Telephone Number	:	770-881-6205
Fax Number	:

Provider Business Practice Location Address
First Line	:	154 W SPRINGBROOK DR
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-1758
Country	:	US
Telephone Number	:	770-881-6205
Fax Number	:

Authorized Official
Title or Position	:	CEO/OWNER
Name	:	KIMBERLY LORRAINE BREWER
Credential	:	FNP-C
Telephone Number	:	770-881-6205

Provider Enumeration Date	:	09/18/2013
Last Update Date	:	09/18/2013

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