Healthcare Provider Details

I. General information

NPI: 1629703210
Provider Name (Legal Business Name): PREMIER PHYSICAL THERAPY OF SE TN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2022
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 LIFESTYLE WAY STE 3
BENTON TN
37307-3914
US

IV. Provider business mailing address

PO BOX 923
BENTON TN
37307-0923
US

V. Phone/Fax

Practice location:
  • Phone: 423-464-4884
  • Fax: 833-333-1455
Mailing address:
  • Phone: 423-464-4884
  • Fax: 833-333-1455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MELISSA CLARY
Title or Position: OFFICE MANAGER/BILLING SPECIALIST
Credential:
Phone: 423-464-4884