Healthcare Provider Details

I. General information

NPI: 1285203828
Provider Name (Legal Business Name): TANNER RICHEY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 06/18/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5044 FRANKFORD AVE
LUBBOCK TX
79424-1146
US

IV. Provider business mailing address

4110 22ND PL
LUBBOCK TX
79410-1122
US

V. Phone/Fax

Practice location:
  • Phone: 806-792-7200
  • Fax: 806-792-7225
Mailing address:
  • Phone: 806-792-4329
  • Fax: 806-792-9466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3127342
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: