Healthcare Provider Details

I. General information

NPI: 1003909110
Provider Name (Legal Business Name): KENNETH WOODRUFF RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9047 EXECUTIVE PARK DR SUITE 115
KNOXVILLE TN
37923-4605
US

IV. Provider business mailing address

9047 EXECUTIVE PARK DR SUITE 115
KNOXVILLE TN
37923-4605
US

V. Phone/Fax

Practice location:
  • Phone: 865-531-5820
  • Fax: 865-539-6461
Mailing address:
  • Phone: 865-531-5820
  • Fax: 865-539-6461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number5634
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: