Healthcare Provider Details

I. General information

NPI: 1437190279
Provider Name (Legal Business Name): JOHN RAYMOND MIKULA JR. CTRS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 02/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 JEFFERSON AVE
MEMPHIS TN
38104-2127
US

IV. Provider business mailing address

374 SILVERTHORN DR NW
MARIETTA GA
30064
US

V. Phone/Fax

Practice location:
  • Phone: 901-523-8990
  • Fax:
Mailing address:
  • Phone: 352-246-2124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number43701
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: