Healthcare Provider Details

I. General information

NPI: 1275933384
Provider Name (Legal Business Name): INDEPENDENT PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2014
Last Update Date: 08/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2946 WINFIELD DUNN PKWY STE 106
KODAK TN
37764-4318
US

IV. Provider business mailing address

8823 PRODUCTION LN
OOLTEWAH TN
37363-6511
US

V. Phone/Fax

Practice location:
  • Phone: 865-932-1088
  • Fax: 865-932-1454
Mailing address:
  • Phone: 423-238-7217
  • Fax: 423-954-7399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LISA BENETTO
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 423-238-8923