Provider Demographics
NPI:1023550100
Name:YOUR ENT, PLLC
Entity Type:Organization
Organization Name:YOUR ENT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:LENDERMAN
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:901-861-2526
Mailing Address - Street 1:2028 W POPLAR AVE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-0618
Mailing Address - Country:US
Mailing Address - Phone:901-861-2526
Mailing Address - Fax:901-861-2527
Practice Address - Street 1:2028 W POPLAR AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-0618
Practice Address - Country:US
Practice Address - Phone:901-861-2526
Practice Address - Fax:901-861-2527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-07
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15081261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1519558Medicaid
TNP00873707OtherMEDICARE RAILROAD
MS01434865Medicaid
TN5073174OtherCIGNA
AR183493758Medicaid
TN4270955OtherBLUE CROSS/BLUE SHIELD
MO1740591437Medicaid
TN3196332OtherUNITED HEALTH CARE
MS01434865Medicaid