Healthcare Provider Details

I. General information

NPI: 1962530535
Provider Name (Legal Business Name): MACHA J ROSS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 N MAIN ST
TENNESSEE RIDGE TN
37178-4003
US

IV. Provider business mailing address

1330 N MAIN ST
TENNESSEE RIDGE TN
37178-4003
US

V. Phone/Fax

Practice location:
  • Phone: 931-721-3337
  • Fax: 931-721-3308
Mailing address:
  • Phone: 931-721-3337
  • Fax: 931-721-3308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: