Provider Demographics
NPI:1629354600
Name:TENBROECK, JOHN SCOTT (LNHA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:SCOTT
Last Name:TENBROECK
Suffix:
Gender:M
Credentials:LNHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:936 N SHARON AMITY RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-3138
Mailing Address - Country:US
Mailing Address - Phone:704-942-0650
Mailing Address - Fax:
Practice Address - Street 1:936 N SHARON AMITY RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-3138
Practice Address - Country:US
Practice Address - Phone:704-942-0650
Practice Address - Fax:704-333-2281
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-23
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA00001102171M00000X
172V00000X, 174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker