Provider Demographics
NPI:1437389731
Name:HEALTHY LIFE CLINIC, INC.
Entity Type:Organization
Organization Name:HEALTHY LIFE CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:BICKFORD
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:865-247-6340
Mailing Address - Street 1:110 PERIMETER PARK RD.
Mailing Address - Street 2:SUITE G
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-2200
Mailing Address - Country:US
Mailing Address - Phone:865-247-6340
Mailing Address - Fax:865-951-2617
Practice Address - Street 1:110 PERIMETER PARK RD.
Practice Address - Street 2:SUITE G
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-2200
Practice Address - Country:US
Practice Address - Phone:865-247-6340
Practice Address - Fax:865-951-2617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-21
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000012264363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1517282Medicaid