Basic Information
| Provider Information | |||||||||
| NPI: | 1417361049 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32569 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379302569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656940062 | ||||||||
| FaxNumber: | 8656947907 | ||||||||
| Practice Location | |||||||||
| Address1: | 9430 PARK WEST BLVD | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379234200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656904861 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2014 | ||||||||
| LastUpdateDate: | 10/24/2017 | ||||||||
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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 | 225100000X | 9993 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | Q007022 | 05 | TN | MEDICAID |