Provider Demographics
NPI:1922706589
Name:FLINTZ, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:FLINTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4896 MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TN
Mailing Address - Zip Code:37347-3682
Mailing Address - Country:US
Mailing Address - Phone:423-269-2608
Mailing Address - Fax:
Practice Address - Street 1:4896 MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TN
Practice Address - Zip Code:37347-3682
Practice Address - Country:US
Practice Address - Phone:423-269-2608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN11111111111111OtherPRIVATE PAY/ VA