Provider Demographics
NPI:1114462215
Name:NEW LIFE MEDICINE
Entity Type:Organization
Organization Name:NEW LIFE MEDICINE
Other - Org Name:NEW LIFE MEDICINE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TACKLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-434-6677
Mailing Address - Street 1:2408 SUSANNAH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1765
Mailing Address - Country:US
Mailing Address - Phone:423-434-6677
Mailing Address - Fax:423-461-0000
Practice Address - Street 1:2408 SUSANNAH ST STE 1
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1765
Practice Address - Country:US
Practice Address - Phone:423-434-6677
Practice Address - Fax:423-461-0000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-27
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RA0401X, 251S00000X, 261QM1300X, 261QR0405X, 261QR0405X
TN45404207RA0401X
TN2674207RA0401X
TN29406207VG0400X
TN47972207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ026013Medicaid
VA2017139831Medicaid
KY7100519480Medicaid
TNQ006701Medicaid
TNQ029839Medicaid
TNQ004992Medicaid
TNQ012811Medicaid