Basic Information
| Provider Information | |||||||||
| NPI: | 1962628578 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STARK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MITCHELL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 344 HOMEVILLE RD | ||||||||
| Address2: | |||||||||
| City: | COLLIERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380172310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016475236 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2100 EXETER RD | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381383922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017571350 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA0000002893 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.