Provider Demographics
NPI:1053583674
Name:CENTER FOR PHYSICAL MEDICINE
Entity type:Organization
Organization Name:CENTER FOR PHYSICAL MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:DEATON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:931-438-0611
Mailing Address - Street 1:1822 HUNTSVILLE HWY STE D
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-3788
Mailing Address - Country:US
Mailing Address - Phone:931-438-0611
Mailing Address - Fax:931-438-0622
Practice Address - Street 1:1822 HUNTSVILLE HWY STE D
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-3788
Practice Address - Country:US
Practice Address - Phone:931-438-0611
Practice Address - Fax:931-438-0622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1277111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNDD4186OtherRAILROAD MEDICARE
TN3120641OtherBCBS OF TN
TNU70349Medicare UPIN
TN3120641OtherBCBS OF TN