1366020588 NPI number — MRS. REBECCA L SWAFFORD APN

Table of content: MRS. REBECCA L SWAFFORD APN (NPI 1366020588)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366020588 NPI number — MRS. REBECCA L SWAFFORD APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SWAFFORD
Provider First Name:
REBECCA
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

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:
1366020588
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
474 MUDDY POND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTEREY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38574-3829
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-787-8317
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4147 HIGHWAY 127 N STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROSSVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38571-7521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-484-2220
Provider Business Practice Location Address Fax Number:
931-484-2220
Provider Enumeration Date:
03/30/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  29174 , 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)

  • Identifier: Q066057 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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