Healthcare Provider Details

I. General information

NPI: 1205478153
Provider Name (Legal Business Name): ZACHARY BUMGARNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2019
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 CALEDON CT STE B
GREENVILLE SC
29615-3170
US

IV. Provider business mailing address

1321 MURFREESBORO PIKE STE 702
NASHVILLE TN
37217-2679
US

V. Phone/Fax

Practice location:
  • Phone: 864-631-2084
  • Fax: 615-577-5654
Mailing address:
  • Phone: 844-359-7629
  • Fax: 615-577-5654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: