Provider Demographics
NPI:1508091562
Name:EAST TENNESSEE STATE UNIVERSITY
Entity Type:Organization
Organization Name:EAST TENNESSEE STATE UNIVERSITY
Other - Org Name:DAVID CROCKETT HIGH SCHOOL BASED HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACTING CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:J
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-439-4414
Mailing Address - Street 1:365 STOUT DRIVE BOX 70403
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37614-1703
Mailing Address - Country:US
Mailing Address - Phone:423-439-4071
Mailing Address - Fax:423-439-4060
Practice Address - Street 1:684 OLD STATE ROUTE 34
Practice Address - Street 2:
Practice Address - City:JONESBOROUGH
Practice Address - State:TN
Practice Address - Zip Code:37659-6094
Practice Address - Country:US
Practice Address - Phone:423-753-0057
Practice Address - Fax:423-753-1167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-20
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty