Healthcare Provider Details

I. General information

NPI: 1457371718
Provider Name (Legal Business Name): JOHN R BOUCHER P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 10/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 W BADDOUR PKWY SUITE C
LEBANON TN
37087-2656
US

IV. Provider business mailing address

1430 W BADDOUR PKWY SUITE C
LEBANON TN
37087-2656
US

V. Phone/Fax

Practice location:
  • Phone: 615-453-1422
  • Fax: 615-453-1429
Mailing address:
  • Phone: 615-453-1422
  • Fax: 615-453-1429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05269
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: