Healthcare Provider Details

I. General information

NPI: 1457361396
Provider Name (Legal Business Name): ELIZABETH ANN THACKER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 E MAIN ST
ADAMSVILLE TN
38310-2450
US

IV. Provider business mailing address

524 E MAIN ST P.O. BOX 169
ADAMSVILLE TN
38310-2450
US

V. Phone/Fax

Practice location:
  • Phone: 731-632-1048
  • Fax:
Mailing address:
  • Phone: 731-632-1048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3309
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: