Provider Demographics
NPI:1225352164
Name:SALE CREEK FAMILY PRACTICE, PLLC
Entity Type:Organization
Organization Name:SALE CREEK FAMILY PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:423-332-1813
Mailing Address - Street 1:PO BOX 746
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37401-0746
Mailing Address - Country:US
Mailing Address - Phone:423-877-2312
Mailing Address - Fax:423-877-5855
Practice Address - Street 1:108 GRIFFITH ST
Practice Address - Street 2:
Practice Address - City:SALE CREEK
Practice Address - State:TN
Practice Address - Zip Code:37373-9715
Practice Address - Country:US
Practice Address - Phone:423-332-1813
Practice Address - Fax:423-332-7732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1671207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty