Healthcare Provider Details

I. General information

NPI: 1760502520
Provider Name (Legal Business Name): SOUTHERN REHAB & AQUATICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 DIXIE LEE CENTER RD SUITE A
KIMBALL TN
37347-5672
US

IV. Provider business mailing address

400 DIXIE LEE CENTER RD
KIMBALL TN
37347-5672
US

V. Phone/Fax

Practice location:
  • Phone: 423-837-7536
  • Fax: 423-837-7538
Mailing address:
  • Phone: 423-837-7536
  • Fax: 423-837-7538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT0000006009
License Number StateTN

VIII. Authorized Official

Name: MR. TRACE DEWAYNE KENNEMORE
Title or Position: PT
Credential: PT
Phone: 423-837-7536