MEDICARE: PHYSIOONE PHYSICAL THERAPY, PLLC

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

General Provider Information

NPI Number	:	1811515778
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSIOONE PHYSICAL THERAPY, PLLC

Provider Business Mailing Address
First Line	:	1204 N HOUSTON LEVEE RD STE 106
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38018-6687
Country	:	US
Telephone Number	:	901-410-8487
Fax Number	:

Provider Business Practice Location Address
First Line	:	1204 N HOUSTON LEVEE RD STE 106
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38018-6687
Country	:	US
Telephone Number	:	901-410-8487
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	GARY CLOUSE
Credential	:	DPT
Telephone Number	:	318-639-7646

Provider Enumeration Date	:	07/08/2020
Last Update Date	:	07/08/2020

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