Provider Demographics
NPI:1932750189
Name:ETLOG MANAGEMENT SERVICE
Entity type:Organization
Organization Name:ETLOG MANAGEMENT SERVICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:YAW
Authorized Official - Middle Name:
Authorized Official - Last Name:OTCHERE-BOATENG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-677-7040
Mailing Address - Street 1:1005 CARRINGTON CT
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-5694
Mailing Address - Country:US
Mailing Address - Phone:423-677-7040
Mailing Address - Fax:
Practice Address - Street 1:1005 CARRINGTON CT
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-5694
Practice Address - Country:US
Practice Address - Phone:423-677-7040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ETLOG MANAGEMENT SERVICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-09-27
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA
No291U00000XLaboratoriesClinical Medical Laboratory
No251B00000XAgenciesCase Management
No251J00000XAgenciesNursing Care
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children