MEDICARE: 1 TEAM LLC TAZEWELL

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	363LF0000X	Family Nurse Practitioner	1366442782	TN

General Provider Information

NPI Number	:	1710425368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1 TEAM LLC TAZEWELL

Provider Business Mailing Address
First Line	:	PO BOX 416
Second Line	:
City	:	GREENEVILLE
State	:	TN
Zip	:	37744-0416
Country	:	US
Telephone Number	:	423-639-0187
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 HESTER LN
Second Line	:
City	:	TAZEWELL
State	:	TN
Zip	:	37879-5088
Country	:	US
Telephone Number	:	423-851-1149
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. CHARLES C. DOTY JR.
Credential	:
Telephone Number	:	423-639-0187

Provider Enumeration Date	:	02/03/2017
Last Update Date	:	02/03/2017

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