Healthcare Provider Details

I. General information

NPI: 1124497730
Provider Name (Legal Business Name): WELLNESS ONE MEMPHIS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2015
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 PRIMACY PKWY STE 112
MEMPHIS TN
38119-0705
US

IV. Provider business mailing address

6100 PRIMACY PKWY STE 112
MEMPHIS TN
38119-0705
US

V. Phone/Fax

Practice location:
  • Phone: 901-682-5335
  • Fax: 901-682-5440
Mailing address:
  • Phone: 901-682-5335
  • Fax: 901-682-5440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RUSSELL D RADICAN
Title or Position: PRESIDENT
Credential: DC
Phone: 901-682-5335