Basic Information
| Provider Information | |||||||||
| NPI: | 1134649064 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TEDDER | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | JR. | ||||||||
| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1446 | ||||||||
| Address2: | |||||||||
| City: | LEICESTER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287481446 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 RICEVILLE RD | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288052122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282991110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2017 | ||||||||
| LastUpdateDate: | 06/21/2017 | ||||||||
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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 | 225200000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.