Provider Demographics
NPI:1427829696
Name:VITAL CARE CLINIC OF ESTILL SPRINGS
Entity type:Organization
Organization Name:VITAL CARE CLINIC OF ESTILL SPRINGS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:WOOTEN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:615-612-9397
Mailing Address - Street 1:PO BOX 85
Mailing Address - Street 2:
Mailing Address - City:ESTILL SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:37330-0085
Mailing Address - Country:US
Mailing Address - Phone:615-612-9397
Mailing Address - Fax:
Practice Address - Street 1:300 S MAIN ST # A
Practice Address - Street 2:
Practice Address - City:ESTILL SPRINGS
Practice Address - State:TN
Practice Address - Zip Code:37330-4042
Practice Address - Country:US
Practice Address - Phone:615-612-9397
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-15
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty