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General NPI Number Information
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NPI Number | 1639393283
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Entity Type | Individual
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Provider Name | KEVIN WAYNE PRIDMORE P.T.
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Gender | Male
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Dates
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Enumeration Date | 04/13/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 326 ASBURY AVE
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City | RIPLEY
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State | TN
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Zip | 38063-5577
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Country | US
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Telephone | 731-221-2478
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Fax | 731-221-2255
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Provider Business Mailing Address
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Address Line | 5419 PORTERSVILLE RD
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City | ATOKA
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State | TN
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Zip | 38004-7331
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Country | US
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Telephone | 901-840-2359
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Fax | 731-221-2255
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 6702
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License Number State | TN
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