Healthcare Provider Details

I. General information

NPI: 1558901736
Provider Name (Legal Business Name): AT HOME PHYSICAL REHABILITATION GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

856 WILLOW TREE CIRCLE
CORDOVA TN
38018
US

IV. Provider business mailing address

856 WILLOW TREE CIRCLE
CORDOVA TN
38018
US

V. Phone/Fax

Practice location:
  • Phone: 901-794-7988
  • Fax: 901-794-7877
Mailing address:
  • Phone: 901-794-7988
  • Fax: 901-794-7877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. ROQUE FLESTADO ESTIPONA JR.
Title or Position: CEO/ADMINISTRATOR
Credential: PT, DPT
Phone: 901-461-5787