Healthcare Provider Details

I. General information

NPI: 1629502968
Provider Name (Legal Business Name): EARL ROBERTSON CP, LPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 N WHITE STATION RD
MEMPHIS TN
38122-4422
US

IV. Provider business mailing address

722 N WHITE STATION RD
MEMPHIS TN
38122-4422
US

V. Phone/Fax

Practice location:
  • Phone: 901-763-6999
  • Fax: 901-682-9062
Mailing address:
  • Phone: 901-763-6999
  • Fax: 901-682-9062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberLO 58
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberLP 49
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: