Provider Demographics
NPI:1467992446
Name:EASTLAKE MEDICAL, LLC
Entity type:Organization
Organization Name:EASTLAKE MEDICAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-494-9673
Mailing Address - Street 1:2500 JACKSBORO PIKE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:JACKSBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37757
Mailing Address - Country:US
Mailing Address - Phone:423-352-6500
Mailing Address - Fax:423-352-6501
Practice Address - Street 1:2205 JACKSBORO PIKE
Practice Address - Street 2:
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-2904
Practice Address - Country:US
Practice Address - Phone:423-352-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-24
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR1300X
TN261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
6065731OtherAETNA
TNQ028641Medicaid