Provider Demographics
NPI:1851902639
Name:ADDICTION RECOVERY CENTER OF EAST TN
Entity Type:Organization
Organization Name:ADDICTION RECOVERY CENTER OF EAST TN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MACK
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-914-3195
Mailing Address - Street 1:3763 HIGHWAY 11 W
Mailing Address - Street 2:
Mailing Address - City:BLOUNTVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37617-3407
Mailing Address - Country:US
Mailing Address - Phone:423-279-3860
Mailing Address - Fax:423-279-3861
Practice Address - Street 1:3763 HIGHWAY 11 W
Practice Address - Street 2:
Practice Address - City:BLOUNTVILLE
Practice Address - State:TN
Practice Address - Zip Code:37617-3407
Practice Address - Country:US
Practice Address - Phone:423-279-3860
Practice Address - Fax:423-279-3861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction MedicineGroup - Single Specialty