Healthcare Provider Details

I. General information

NPI: 1225366487
Provider Name (Legal Business Name): MR. RUNNIE DEWAYNE JEFFERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2009
Last Update Date: 11/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

996 PALMER RD
MEMPHIS TN
38116-7724
US

IV. Provider business mailing address

996 PALMER RD
MEMPHIS TN
38116-7724
US

V. Phone/Fax

Practice location:
  • Phone: 980-133-2040
  • Fax: 901-332-0402
Mailing address:
  • Phone: 901-332-0402
  • Fax: 901-332-0402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number52362989
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: