Healthcare Provider Details

I. General information

NPI: 1871125146
Provider Name (Legal Business Name): SENIORWELL POD OF TENNESSEE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2020
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 POPLAR AVE FL 27
MEMPHIS TN
38137-2701
US

IV. Provider business mailing address

2100 E LAKE COOK RD STE 1000
BUFFALO GROVE IL
60089-1999
US

V. Phone/Fax

Practice location:
  • Phone: 844-882-3127
  • Fax:
Mailing address:
  • Phone: 844-882-3127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: JOHN MORONEY
Title or Position: CEO
Credential:
Phone: 844-882-3127