Basic Information
| Provider Information | |||||||||
| NPI: | 1275623522 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ORTHOTENNESSEE, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ORTHOTENNESSEE ORTHOTICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 90 VERMONT AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | OAK RIDGE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378306474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8654829025 | ||||||||
| FaxNumber: | 8654838151 | ||||||||
| Practice Location | |||||||||
| Address1: | 90 VERMONT AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | OAK RIDGE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378306474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8654829025 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2006 | ||||||||
| LastUpdateDate: | 12/02/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEESON | ||||||||
| AuthorizedOfficialFirstName: | JON-DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8657694545 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.