Healthcare Provider Details

I. General information

NPI: 1316470883
Provider Name (Legal Business Name): MRS. RACHEL SIDLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6515 POPLAR AVE STE 112
MEMPHIS TN
38119-4878
US

IV. Provider business mailing address

6515 POPLAR AVE STE 112
MEMPHIS TN
38119-4878
US

V. Phone/Fax

Practice location:
  • Phone: 901-795-1776
  • Fax: 901-795-1738
Mailing address:
  • Phone: 901-795-1776
  • Fax: 901-795-1738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number195
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number215
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: