Basic Information
| Provider Information | |||||||||
| NPI: | 1598256117 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMMAUS MEDICAL AND COUNSELING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 273 HIGHWAY 11 E | ||||||||
| Address2: | |||||||||
| City: | BULLS GAP | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377113433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233934146 | ||||||||
| FaxNumber: | 4233934377 | ||||||||
| Practice Location | |||||||||
| Address1: | 273 HIGHWAY 11 E | ||||||||
| Address2: | |||||||||
| City: | BULLS GAP | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377113433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233934146 | ||||||||
| FaxNumber: | 4233934377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2018 | ||||||||
| LastUpdateDate: | 10/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | HENEGAR | ||||||||
| AuthorizedOfficialFirstName: | JUDY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4233412570 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0401X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine |
No ID Information.