Basic Information
| Provider Information | |||||||||
| NPI: | 1164590311 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TENNESSEE THERAPY SERVICES, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ARDMORE/PULASKI PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 203 VILLAGE SQ | ||||||||
| Address2: | |||||||||
| City: | PULASKI | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384782929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9314245588 | ||||||||
| FaxNumber: | 9314245590 | ||||||||
| Practice Location | |||||||||
| Address1: | 203 VILLAGE SQ | ||||||||
| Address2: | |||||||||
| City: | PULASKI | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384782929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9314245588 | ||||||||
| FaxNumber: | 9314245590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 05/15/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NEWTON | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9314245588 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 4033548 | 01 | TN | BLUE CROSS NUMBER | OTHER | 3151382 | 01 | TN | GROUP BLUE CROSS NUMBER | OTHER | 3655850 | 01 | TN | PTAN | OTHER | 4069718 | 01 | TN | PTAN | OTHER |