Basic Information
| Provider Information | |||||||||
| NPI: | 1225352164 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SALE CREEK FAMILY PRACTICE, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 746 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374010746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238772312 | ||||||||
| FaxNumber: | 4238775855 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 GRIFFITH ST | ||||||||
| Address2: | |||||||||
| City: | SALE CREEK | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373739715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233321813 | ||||||||
| FaxNumber: | 4233327732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2010 | ||||||||
| LastUpdateDate: | 03/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | BLACK | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4233321813 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1671 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.