MEDICARE: TERRELL SEAN TATE BOCP, CO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1744P3200X	Prosthetics Case Management	PRO130	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PRO130	OTHER	TN	TN DEPT OF HEALTH DIVISION OF RELATED BOARDS

General Provider Information

NPI Number	:	1164929543
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERRELL SEAN TATE BOCP, CO

Provider Business Mailing Address
First Line	:	1661 INTERNATIONAL PLACE DR STE 400
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38120-1431
Country	:	US
Telephone Number	:	901-818-3175
Fax Number	:

Provider Business Practice Location Address
First Line	:	1661 INTERNATIONAL DRIVE
Second Line	:	SUITE 400
City	:	MEMPHIS
State	:	TN
Zip	:	38120-1431
Country	:	US
Telephone Number	:	901-340-2008
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2018
Last Update Date	:	05/28/2021

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Directions to “ TERRELL SEAN TATE BOCP, CO” Practice Location

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