Individual
GRANT HOLDER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
3105 ESSARY DR, KNOXVILLE, TN 37918-2409
(865) 256-0573
Mailing address
12717 BROKEN SADDLE RD, KNOXVILLE, TN 37934-1329
Taxonomy
Speciality
Code
Description
License number
State
390200000X
Student in an Organized Health Care Education/Training Program
Primary
—
—
Other
Enumeration date
01/22/2024
Last updated
01/22/2024
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