1437294782 NPI number — MR. JAMES CECIL BRISTOW

Table of content: MR. JAMES CECIL BRISTOW (NPI 1437294782)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437294782 NPI number — MR. JAMES CECIL BRISTOW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRISTOW
Provider First Name:
JAMES
Provider Middle Name:
CECIL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRISTOW
Provider Other First Name:
REBECCA
Provider Other Middle Name:
IDELLANN
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LDO
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1437294782
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1541 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CROSSVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38555-6738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-484-9398
Provider Business Mailing Address Fax Number:
931-484-9398

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1541 N MAIN ST
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:
38555-6738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-484-9398
Provider Business Practice Location Address Fax Number:
931-484-9398
Provider Enumeration Date:
02/21/2007

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: 156FX1800X , with the licence number:  1376 , 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)