Healthcare Provider Details

I. General information

NPI: 1316978612
Provider Name (Legal Business Name): EDDIE LEE CROCKER PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 SHELBY DR
DYERSBURG TN
38024-3435
US

IV. Provider business mailing address

1400 SHELBY DR
DYERSBURG TN
38024-3435
US

V. Phone/Fax

Practice location:
  • Phone: 731-288-5056
  • Fax: 731-288-5067
Mailing address:
  • Phone: 731-288-5056
  • Fax: 731-288-5067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT0000002313
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: