Basic Information
| Provider Information | |||||||||
| NPI: | 1700055977 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHATTANOOGA SPINE & SPORT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2307 NAPIER RD STE 103 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374211827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238949893 | ||||||||
| FaxNumber: | 4238940992 | ||||||||
| Practice Location | |||||||||
| Address1: | 2307 NAPIER RD STE 103 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374211827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238949893 | ||||||||
| FaxNumber: | 4238940992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2008 | ||||||||
| LastUpdateDate: | 02/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | PEREZ | ||||||||
| AuthorizedOfficialFirstName: | LOREN | ||||||||
| AuthorizedOfficialMiddleName: | HEATH | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4238949893 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MSPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT0000004942 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 4170264 | 01 | TN | BLUECROSS BLUESHIELD | OTHER |