Provider Demographics
NPI:1518393818
Name:TRI CITIES MEN'S HEALTH
Entity Type:Organization
Organization Name:TRI CITIES MEN'S HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:LORRAINE
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:770-881-6205
Mailing Address - Street 1:154 W SPRINGBROOK DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-1758
Mailing Address - Country:US
Mailing Address - Phone:770-881-6205
Mailing Address - Fax:
Practice Address - Street 1:154 W SPRINGBROOK DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-1758
Practice Address - Country:US
Practice Address - Phone:770-881-6205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN85103261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care