Basic Information
| Provider Information | |||||||||
| NPI: | 1114267986 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFT THERAPY, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | LIFT THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 JACKSON WALK PLAZA | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314216950 | ||||||||
| FaxNumber: | 7314216999 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 JACKSON WALK PLAZA | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314216950 | ||||||||
| FaxNumber: | 7314216999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2013 | ||||||||
| LastUpdateDate: | 03/01/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROSS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 7315415000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 0446707 | 05 | TN | MEDICAID |