Healthcare Provider Details

I. General information

NPI: 1821203670
Provider Name (Legal Business Name): LANNY RAY BETHEL PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 HANNINGS LN
MARTIN TN
38237-3308
US

IV. Provider business mailing address

525 MOUNT PELIA RD APT 16
MARTIN TN
38237-3398
US

V. Phone/Fax

Practice location:
  • Phone: 731-587-3193
  • Fax: 731-588-2732
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2032
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: