Healthcare Provider Details

I. General information

NPI: 1861761769
Provider Name (Legal Business Name): NELSON BLAKE GILES EMT-IV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2011
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

956 LEATH ST
MEMPHIS TN
38107-2615
US

IV. Provider business mailing address

956 LEATH ST
MEMPHIS TN
38107-2615
US

V. Phone/Fax

Practice location:
  • Phone: 901-834-2900
  • Fax:
Mailing address:
  • Phone: 901-834-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number104882749
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code146M00000X
TaxonomyIntermediate Emergency Medical Technician
License Number37400
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: