Provider Demographics
NPI:1063433704
Name:SPRING CITY WALK IN MEDICAL CENTER, LLC
Entity type:Organization
Organization Name:SPRING CITY WALK IN MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-452-9984
Mailing Address - Street 1:PO BOX 709
Mailing Address - Street 2:
Mailing Address - City:SPRING CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37381-0709
Mailing Address - Country:US
Mailing Address - Phone:423-452-9980
Mailing Address - Fax:423-452-9980
Practice Address - Street 1:126 LAVENDER ST
Practice Address - Street 2:
Practice Address - City:SPRING CITY
Practice Address - State:TN
Practice Address - Zip Code:37381-5102
Practice Address - Country:US
Practice Address - Phone:423-452-9984
Practice Address - Fax:423-452-9980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44-3943261QR1300X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN443943OtherRURAL HEALTH CLINIC
TN3725140Medicare ID - Type UnspecifiedMEDICARE GROUP #
TN443943Medicare Oscar/Certification