Healthcare Provider Details

I. General information

NPI: 1942381207
Provider Name (Legal Business Name): BANYAN HEALTHCARE & WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 04/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 MCARTHUR ST
MANCHESTER TN
37355-2453
US

IV. Provider business mailing address

1030 MCARTHUR ST
MANCHESTER TN
37355-2453
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number StateTN

VIII. Authorized Official

Name: JAMES EDWARD ROTH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 615-943-9294