Provider Demographics
NPI:1205356813
Name:ELK VALLEY MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:ELK VALLEY MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KARISSA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KRISHNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-619-3243
Mailing Address - Street 1:305 COLLEGE ST W
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-2911
Mailing Address - Country:US
Mailing Address - Phone:931-297-4525
Mailing Address - Fax:888-696-1054
Practice Address - Street 1:305 COLLEGE ST W
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-2911
Practice Address - Country:US
Practice Address - Phone:931-619-3243
Practice Address - Fax:888-696-1054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care