Healthcare Provider Details

I. General information

NPI: 1689405706
Provider Name (Legal Business Name): SHANE HARGIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2024
Last Update Date: 08/10/2024
Certification Date: 08/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 JACK DANCE ST
KNOXVILLE TN
37919-5576
US

IV. Provider business mailing address

1200 CORPORATE DR STE 400
HOOVER AL
35242-5424
US

V. Phone/Fax

Practice location:
  • Phone: 865-691-8381
  • Fax:
Mailing address:
  • Phone: 423-933-1260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number15571
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: