Basic Information
| Provider Information | |||||||||
| NPI: | 1346759636 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENSEMBLE RECOVERY ENTERPRISES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5777 | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378025777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652462104 | ||||||||
| FaxNumber: | 8652462106 | ||||||||
| Practice Location | |||||||||
| Address1: | 417 HOLLY ST | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379177815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8657704003 | ||||||||
| FaxNumber: | 8652462106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2017 | ||||||||
| LastUpdateDate: | 09/29/2017 | ||||||||
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| AuthorizedOfficialLastName: | SHATTUCK | ||||||||
| AuthorizedOfficialFirstName: | DEAVER | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8657703838 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 27892 | TN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363LF0000X | 21354 | TN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 1041C0700X | 3550 | TN | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.