Provider Demographics
NPI:1053640193
Name:ADVANCED THERAPY OF KINGSPORT
Entity Type:Organization
Organization Name:ADVANCED THERAPY OF KINGSPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/P.T.
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:TALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:423-230-6323
Mailing Address - Street 1:1101 E STONE DR STE 3
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3384
Mailing Address - Country:US
Mailing Address - Phone:423-230-6323
Mailing Address - Fax:
Practice Address - Street 1:1101 E STONE DR STE 3
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3384
Practice Address - Country:US
Practice Address - Phone:423-230-6323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-21
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty