Healthcare Provider Details

I. General information

NPI: 1790999456
Provider Name (Legal Business Name): STEPHEN D RAINES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 06/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 COOK ST
DYERSBURG TN
38024-1882
US

IV. Provider business mailing address

1415 E REELFOOT AVE
UNION CITY TN
38261-5812
US

V. Phone/Fax

Practice location:
  • Phone: 731-286-2139
  • Fax: 731-286-2201
Mailing address:
  • Phone: 731-885-0220
  • Fax: 731-885-0216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberDPM217
License Number StateTN

VIII. Authorized Official

Name: DR. STEPHEN D RAINES
Title or Position: OWNER
Credential: DPM
Phone: 731-885-0220