Provider Demographics
NPI:1972043214
Name:EASTLAKE PRIMARY CARE LLC
Entity Type:Organization
Organization Name:EASTLAKE PRIMARY CARE LLC
Other - Org Name:EASTLAKE PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MIESEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-352-6500
Mailing Address - Street 1:2500 JACKSBORO PIKE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:JACKSBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37757
Mailing Address - Country:US
Mailing Address - Phone:423-352-6500
Mailing Address - Fax:423-352-6501
Practice Address - Street 1:2500 JACKSBORO PIKE STE 6
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TN
Practice Address - Zip Code:37757-2818
Practice Address - Country:US
Practice Address - Phone:423-352-6500
Practice Address - Fax:423-352-6501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN261QP2300X
261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ027747Medicaid