Healthcare Provider Details

I. General information

NPI: 1811304439
Provider Name (Legal Business Name): MEMPHIS SPINE AND REHAB CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2014
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2645 APPLING RD STE 103
MEMPHIS TN
38133-5088
US

IV. Provider business mailing address

7796 WOLF TRAIL CV STE 1022645
MEMPHIS TN
38138-1782
US

V. Phone/Fax

Practice location:
  • Phone: 901-751-0939
  • Fax: 901-751-0332
Mailing address:
  • Phone: 901-751-0939
  • Fax: 901-751-0332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LINDA SUE PETTY
Title or Position: OFFICE MANAGER
Credential:
Phone: 901-751-0939