1114905643 NPI number — BENTON COUNTY PHYSICAL THERAPY

Table of content: (NPI 1114905643)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114905643 NPI number — BENTON COUNTY PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BENTON COUNTY PHYSICAL THERAPY
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:
DOVER REHABILITATION SERVICES
Provider Other Organization Name Type Code:
3
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:
1114905643
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 465
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PARIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38242
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-232-0057
Provider Business Mailing Address Fax Number:
931-232-0067

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
543 HIGHWAY 79
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOVER
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37058-5966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-232-0057
Provider Business Practice Location Address Fax Number:
931-232-0067
Provider Enumeration Date:
01/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PINION
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
CORPORATE SECRETARY/OFFICE MANAGER
Authorized Official Telephone Number:
931-232-0057

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT0000002294 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2000X , with the licence number: PT2294 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3106297 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 044-6602 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0446602 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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