Healthcare Provider Details

I. General information

NPI: 1841438736
Provider Name (Legal Business Name): SPECIALTY REHABILITATION GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2009
Last Update Date: 01/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10076 SUTTON RIDGE LN
CORDOVA TN
38016-0685
US

IV. Provider business mailing address

10076 SUTTON RIDGE LN
CORDOVA TN
38016-0685
US

V. Phone/Fax

Practice location:
  • Phone: 901-219-8505
  • Fax: 901-202-0336
Mailing address:
  • Phone: 901-219-8505
  • Fax: 901-202-0336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number0000002224
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0000001006
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number1506
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1807
License Number StateTN

VIII. Authorized Official

Name: MR. RAJU PRATAP
Title or Position: COORDINATOR
Credential:
Phone: 901-219-8505