Provider Demographics
NPI:1417200809
Name:MICHAEL T PETTY DC PLLC
Entity Type:Organization
Organization Name:MICHAEL T PETTY DC PLLC
Other - Org Name:CONCORD CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:865-675-5050
Mailing Address - Street 1:10826 KINGSTON PIKE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-3059
Mailing Address - Country:US
Mailing Address - Phone:865-675-5050
Mailing Address - Fax:865-671-1321
Practice Address - Street 1:10826 KINGSTON PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-3059
Practice Address - Country:US
Practice Address - Phone:865-675-5050
Practice Address - Fax:865-671-1321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC511261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNT74620Medicare UPIN