MEDICARE: MS. CANDICE RHEA BREEDEN PTA

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	225200000X	Physical Therapy Assistant	PTA0000003613	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	183838	OTHER	TN	BLUE CROSS PROVIDER

General Provider Information

NPI Number	:	1467529032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CANDICE RHEA BREEDEN PTA

Provider Business Mailing Address
First Line	:	5146 STAGE RD
Second Line	:	SUITE 102
City	:	MEMPHIS
State	:	TN
Zip	:	38134-3164
Country	:	US
Telephone Number	:	901-380-2727
Fax Number	:	901-380-2722

Provider Business Practice Location Address
First Line	:	5146 STAGE RD
Second Line	:	SUITE 102
City	:	MEMPHIS
State	:	TN
Zip	:	38134-3164
Country	:	US
Telephone Number	:	901-380-2727
Fax Number	:	901-380-2722

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

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	07/08/2007

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