1457679169 NPI number — TENN SPINE AND PERFORMANCE ENHANCEMENT CENTER

Table of content: (NPI 1457679169)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457679169 NPI number — TENN SPINE AND PERFORMANCE ENHANCEMENT CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TENN SPINE AND PERFORMANCE ENHANCEMENT CENTER
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:
TENNESSEE SPINE & PERFORMANCE ENHANCEMENT CENTER
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:
1457679169
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
470 COLLIER DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEVIERVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
57862-6931
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-286-5421
Provider Business Mailing Address Fax Number:
865-286-9937

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
470 COLLIER DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEVIERVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
57862-6931
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-286-5421
Provider Business Practice Location Address Fax Number:
865-286-9937
Provider Enumeration Date:
05/06/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CHAMBERS
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
T
Authorized Official Title or Position:
PROVIDER
Authorized Official Telephone Number:
865-286-5421

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2426 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: DC0000002426 , 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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