Basic Information
| Provider Information | |||||||||
| NPI: | 1740413665 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLEN | ||||||||
| FirstName: | LEWIS | ||||||||
| MiddleName: | FREDRICK | ||||||||
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| Credential: | B.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6350 W ANDREW JOHNSON HWY | ||||||||
| Address2: | DEPARTMENT 100 | ||||||||
| City: | TALBOTT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378778605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003553565 | ||||||||
| FaxNumber: | 4237142355 | ||||||||
| Practice Location | |||||||||
| Address1: | 538 W 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379177109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655252104 | ||||||||
| FaxNumber: | 8655252212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2009 | ||||||||
| LastUpdateDate: | 10/24/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.