Provider Demographics
NPI:1104236421
Name:OSTEOPATHIC CENTER PLLC
Entity type:Organization
Organization Name:OSTEOPATHIC CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTOPHER
Authorized Official - Middle Name:JS
Authorized Official - Last Name:GODDARD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:865-321-1732
Mailing Address - Street 1:9000 EXECUTIVE PARK DR
Mailing Address - Street 2:SUITE A210
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4685
Mailing Address - Country:US
Mailing Address - Phone:865-321-1732
Mailing Address - Fax:865-321-1733
Practice Address - Street 1:9000 EXECUTIVE PARK DR
Practice Address - Street 2:SUITE A210
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4685
Practice Address - Country:US
Practice Address - Phone:865-321-1732
Practice Address - Fax:865-321-1733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-08
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO0000002081207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty