Healthcare Provider Details

I. General information

NPI: 1467492660
Provider Name (Legal Business Name): MARK WESLEY ANDERSON CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 03/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1079 VENDALL RD
DYERSBURG TN
38024-1622
US

IV. Provider business mailing address

659 ANDERSON RD
DYERSBURG TN
38024-8401
US

V. Phone/Fax

Practice location:
  • Phone: 731-286-6006
  • Fax: 731-286-5570
Mailing address:
  • Phone: 731-286-6006
  • Fax: 731-286-5570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: