Healthcare Provider Details

I. General information

NPI: 1356886550
Provider Name (Legal Business Name): KEVIN CODY TUBBS MS, ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2016
Last Update Date: 12/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6286 BRIARCREST AVE
MEMPHIS TN
38120-4023
US

IV. Provider business mailing address

819 BURTON LN
SOUTHAVEN MS
38671-6975
US

V. Phone/Fax

Practice location:
  • Phone: 901-305-4021
  • Fax:
Mailing address:
  • Phone: 901-488-2286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAT0000001799
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAT0637
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: