MEDICARE: JOHN R BOUCHER P.T.

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	225100000X	Physical Therapist	05269	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	05269	OTHER	TN	PHYSICAL THERAPY LICENSE

General Provider Information

NPI Number	:	1457371718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN R BOUCHER P.T.

Provider Business Mailing Address
First Line	:	1430 W BADDOUR PKWY
Second Line	:	SUITE C
City	:	LEBANON
State	:	TN
Zip	:	37087-2656
Country	:	US
Telephone Number	:	615-453-1422
Fax Number	:	615-453-1429

Provider Business Practice Location Address
First Line	:	1430 W BADDOUR PKWY
Second Line	:	SUITE C
City	:	LEBANON
State	:	TN
Zip	:	37087-2656
Country	:	US
Telephone Number	:	615-453-1422
Fax Number	:	615-453-1429

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

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	10/01/2013

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