Provider Demographics
NPI:1578000410
Name:1 TEAM CLINIC LLC
Entity Type:Organization
Organization Name:1 TEAM CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:CALVIN
Authorized Official - Last Name:DOTY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:423-639-0187
Mailing Address - Street 1:PO BOX 416
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37744-0416
Mailing Address - Country:US
Mailing Address - Phone:423-639-0187
Mailing Address - Fax:423-639-2504
Practice Address - Street 1:199 POTTERTOWN RD
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:TN
Practice Address - Zip Code:37809-3213
Practice Address - Country:US
Practice Address - Phone:423-422-4454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1043217352363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty