Provider Demographics
NPI:1073095154
Name:CLASS 'A' CLINIC LLC
Entity Type:Organization
Organization Name:CLASS 'A' CLINIC LLC
Other - Org Name:CLASS 'A' CLINIC LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:CROWDER
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:APN-BC
Authorized Official - Phone:423-720-9111
Mailing Address - Street 1:157 HIGHWAY 25 E
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37821-8157
Mailing Address - Country:US
Mailing Address - Phone:423-720-9111
Mailing Address - Fax:423-301-5756
Practice Address - Street 1:157 HIGHWAY 25 E
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:TN
Practice Address - Zip Code:37821-8157
Practice Address - Country:US
Practice Address - Phone:423-720-9111
Practice Address - Fax:423-301-5756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-05
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16835207QA0505X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ038489Medicaid