Provider Demographics
NPI:1316572530
Name:MOUNTAIN REGION FAMILY MEDICINE, PC
Entity Type:Organization
Organization Name:MOUNTAIN REGION FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-230-2109
Mailing Address - Street 1:444 CLINCHFIELD ST STE 201
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3863
Mailing Address - Country:US
Mailing Address - Phone:423-230-2113
Mailing Address - Fax:423-230-2112
Practice Address - Street 1:390 KANE ST
Practice Address - Street 2:
Practice Address - City:GATE CITY
Practice Address - State:VA
Practice Address - Zip Code:24251-2753
Practice Address - Country:US
Practice Address - Phone:276-386-3411
Practice Address - Fax:276-386-3492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty