Healthcare Provider Details

I. General information

NPI: 1407600919
Provider Name (Legal Business Name): MR. JOSEPH REDDIE QUIAMBAO STUART
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2024
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 JEFFERSON AVE
MEMPHIS TN
38103-2807
US

IV. Provider business mailing address

107 COPLAND CT
GEORGETOWN KY
40324-2158
US

V. Phone/Fax

Practice location:
  • Phone: 901-448-5500
  • Fax:
Mailing address:
  • Phone: 859-967-3051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: