Healthcare Provider Details

I. General information

NPI: 1982972857
Provider Name (Legal Business Name): PROXIMA CENTAURI, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2011
Last Update Date: 10/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 MCARTHUR ST
MANCHESTER TN
37355-2522
US

IV. Provider business mailing address

PO BOX 437
MANCHESTER TN
37349-0437
US

V. Phone/Fax

Practice location:
  • Phone: 931-723-7950
  • Fax: 931-723-7950
Mailing address:
  • Phone: 931-723-7950
  • Fax: 931-723-7815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: JAMES EDWARDS ROTH
Title or Position: PRESIDENT
Credential: MD
Phone: 931-723-7950