=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629260831
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SELF HEALTH AND WELLNESS CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2007
-----------------------------------------------------
Last Update Date | 08/11/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 115 GRESHAM RD
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37918-3209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-687-7600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 115 GRESHAM RD
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37918-3209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-687-7600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUS. OWNER/CHIROPRACTIC PHYSICIAN
-----------------------------------------------------
Name | DR. JOHN MICHAEL SELF JR.
-----------------------------------------------------
Credential | DC, CERT. A/P
-----------------------------------------------------
Telephone | 865-687-7600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 0000001403
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------