=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366119034
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ZACH THORNTON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2021
-----------------------------------------------------
Last Update Date | 09/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 871 RIDGEWAY LOOP RD
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38120-4038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-759-1282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6250 HIGHWAY 64 STE 5
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38060-5175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 13850
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 13850
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------