Healthcare Provider Details

I. General information

NPI: 1003075052
Provider Name (Legal Business Name): PLATINUM PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 08/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1816 N WASHINGTON ST SUITE 101
TULLAHOMA TN
37388
US

IV. Provider business mailing address

1816 N WASHINGTON ST SUITE 101
TULLAHOMA TN
37388
US

V. Phone/Fax

Practice location:
  • Phone: 931-393-2378
  • Fax: 931-455-9983
Mailing address:
  • Phone: 931-393-2378
  • Fax: 931-455-9983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT962
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT3437
License Number StateTN

VIII. Authorized Official

Name: GARY R STEVENS
Title or Position: PARTNER
Credential: DO
Phone: 931-393-2378