Provider Demographics
NPI:1457515371
Name:WHITE SPIRIT LODGE INC.
Entity Type:Organization
Organization Name:WHITE SPIRIT LODGE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MCCARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-577-0530
Mailing Address - Street 1:146 MARYVILLE PIKE
Mailing Address - Street 2:SUTIE 101
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-4185
Mailing Address - Country:US
Mailing Address - Phone:865-577-0530
Mailing Address - Fax:865-577-0430
Practice Address - Street 1:146 MARYVILLE PIKE
Practice Address - Street 2:SUTIE 101
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-4185
Practice Address - Country:US
Practice Address - Phone:865-577-0530
Practice Address - Fax:865-577-0430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN605261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder