Healthcare Provider Details

I. General information

NPI: 1225317597
Provider Name (Legal Business Name): VERZOSA AGUSTIN CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2011
Last Update Date: 08/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1293 HIGHWAY 11W SUITE B
BEAN STATION TN
37708-5810
US

IV. Provider business mailing address

4834 FOWLER DR
MORRISTOWN TN
37814-7704
US

V. Phone/Fax

Practice location:
  • Phone: 423-312-6325
  • Fax:
Mailing address:
  • Phone: 423-312-6315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License NumberPT2169
License Number StateTN

VIII. Authorized Official

Name: MRS. CECILIA AGUSTIN VERZOSA
Title or Position: PRESIDENT
Credential: P.T.
Phone: 423-312-6325