Healthcare Provider Details

I. General information

NPI: 1063819977
Provider Name (Legal Business Name): MARIO NOVO PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2014
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 S HARTMANN DR
LEBANON TN
37090-4064
US

IV. Provider business mailing address

2005 WINTERGREEN WAY
MOUNT JULIET TN
37122-3954
US

V. Phone/Fax

Practice location:
  • Phone: 615-321-0200
  • Fax: 615-443-5488
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10276
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: