Provider Demographics
NPI:1154442861
Name:EAST TENNESSEE VEIN CLINIC, PC
Entity Type:Organization
Organization Name:EAST TENNESSEE VEIN CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DARLA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-686-0507
Mailing Address - Street 1:PO BOX 52333
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37950-2333
Mailing Address - Country:US
Mailing Address - Phone:865-686-0807
Mailing Address - Fax:865-357-8346
Practice Address - Street 1:1344 DOWELL SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909
Practice Address - Country:US
Practice Address - Phone:865-686-0807
Practice Address - Fax:865-357-8346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN202K00000X261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN=========OtherTAX ID NUMBER
TN3709373Medicare ID - Type UnspecifiedMEDICARE GROUP