MEDICARE: KELLY LANE DENNIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2471C3402X	Radiography Radiologic Technologist	CXT0000000596	TN
2	247200000X	Other Technician	CTA0000000761	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CTA0000000761	OTHER	TN	CHIROPRACTIC THERAPY ASSISTANT
2	CXT0000000596	OTHER	TN	CHIROPRACTIC X-RAY TECHNOLOGIST

General Provider Information

NPI Number	:	1205075421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY LANE DENNIS

Provider Business Mailing Address
First Line	:	2425 CHESTER HARRIS RD
Second Line	:
City	:	WOODLAWN
State	:	TN
Zip	:	37191-9054
Country	:	US
Telephone Number	:	931-552-8964
Fax Number	:

Provider Business Practice Location Address
First Line	:	2425 CHESTER HARRIS RD
Second Line	:
City	:	WOODLAWN
State	:	TN
Zip	:	37191-9054
Country	:	US
Telephone Number	:	931-552-8964
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/11/2009
Last Update Date	:	02/11/2009

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