Healthcare Provider Details

I. General information

NPI: 1124228416
Provider Name (Legal Business Name): MT. JULIET SPINE AND PAIN MANAGEMENT, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 03/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 INDUSTRIAL DR STE 7
MOUNT JULIET TN
37122-3168
US

IV. Provider business mailing address

105 INDUSTRIAL DR STE 7
MOUNT JULIET TN
37122-3168
US

V. Phone/Fax

Practice location:
  • Phone: 615-758-7575
  • Fax:
Mailing address:
  • Phone: 615-758-7575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2193
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD0000017958
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPN0000012953
License Number StateTN

VIII. Authorized Official

Name: DR. MICHAEL ANTHONY SWIERCZ
Title or Position: OWNER
Credential: D.C.
Phone: 615-758-7575