MEDICARE: JOHNSON CITY PHYSICAL OCCUPATIONAL SPEECH OUTPATIENT 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	261QR0400X	Rehabilitation Clinic/Center	672988	TN

General Provider Information

NPI Number	:	1992073738
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHNSON CITY PHYSICAL OCCUPATIONAL SPEECH OUTPATIENT THERAPY, PLLC

Provider Business Mailing Address
First Line	:	234 E MAIN ST
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-5708
Country	:	US
Telephone Number	:	904-509-7100
Fax Number	:

Provider Business Practice Location Address
First Line	:	234 E MAIN ST
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-5708
Country	:	US
Telephone Number	:	904-509-7100
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. LANCE A PATE
Credential	:	M.A. CCC-SLP
Telephone Number	:	904-509-7100

Provider Enumeration Date	:	12/07/2011
Last Update Date	:	12/10/2011

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