Healthcare Provider Details

I. General information

NPI: 1336726504
Provider Name (Legal Business Name): CASEY R MOLES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 LONGMIRE RD
CLINTON TN
37716-7338
US

IV. Provider business mailing address

515 S EAST END RD
STRAW PLAINS TN
37871-4425
US

V. Phone/Fax

Practice location:
  • Phone: 865-457-6925
  • Fax:
Mailing address:
  • Phone: 865-221-4136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number6350
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: