MEDICARE: MR. DONALD RAY BOX JR.

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	224P00000X	Prosthetist		TN
2	225000000X	Orthotic Fitter		TN

General Provider Information

NPI Number	:	1184158768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DONALD RAY BOX JR.

Provider Business Mailing Address
First Line	:	6515 POPLAR AVE
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38119-4878
Country	:	US
Telephone Number	:	901-530-7458
Fax Number	:	901-795-1738

Provider Business Practice Location Address
First Line	:	6515 POPLAR AVE
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38119-4878
Country	:	US
Telephone Number	:	901-530-7458
Fax Number	:	901-795-1738

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

Provider Enumeration Date	:	04/20/2017
Last Update Date	:	04/20/2017

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