Provider Demographics
NPI:1598017576
Name:CLINIC FOR PRODUCTIVE LIVING, LLC
Entity Type:Organization
Organization Name:CLINIC FOR PRODUCTIVE LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-394-9337
Mailing Address - Street 1:9217 PARK WEST BLVD
Mailing Address - Street 2:SUITE E1
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4404
Mailing Address - Country:US
Mailing Address - Phone:865-394-9337
Mailing Address - Fax:865-394-9336
Practice Address - Street 1:9217 PARK WEST BLVD
Practice Address - Street 2:SUITE E1
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4404
Practice Address - Country:US
Practice Address - Phone:865-394-9337
Practice Address - Fax:865-394-9336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN11916363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty