1043482193 NPI number — COBURN BACK AND NECK PAIN CLINIC INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043482193 NPI number — COBURN BACK AND NECK PAIN CLINIC INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COBURN BACK AND NECK PAIN CLINIC INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043482193
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8099 STAGE HILLS BLVD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
BARTLETT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38133-4064
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-386-0080
Provider Business Mailing Address Fax Number:
901-382-0089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8099 STAGE HILLS BLVD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
BARTLETT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38133-4064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-386-0080
Provider Business Practice Location Address Fax Number:
901-382-0089
Provider Enumeration Date:
03/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
COBURN
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
901-386-0080

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  1351 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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