Healthcare Provider Details

I. General information

NPI: 1982907853
Provider Name (Legal Business Name): QUINTEN LEWIS SMITH P.T.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2010
Last Update Date: 12/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6564 BARCLAY ST
MILLINGTON TN
38053-8257
US

IV. Provider business mailing address

6564 BARCLAY ST
MILLINGTON TN
38053-8257
US

V. Phone/Fax

Practice location:
  • Phone: 901-491-2337
  • Fax:
Mailing address:
  • Phone: 901-491-2337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA0000001996
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: