Healthcare Provider Details

I. General information

NPI: 1639896624
Provider Name (Legal Business Name): LUCKY MAZE PT, DPT, OCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2022
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5073 MAIN ST STE 140
SPRING HILL TN
37174-2738
US

IV. Provider business mailing address

2011 BLOSSOM RUN
SPRING HILL TN
37174-4542
US

V. Phone/Fax

Practice location:
  • Phone: 615-861-4444
  • Fax:
Mailing address:
  • Phone: 615-913-6862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number16343
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: