Provider Demographics
NPI:1073722443
Name:SELF, JOHN MICHAEL JR (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:SELF
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:115 GRESHAM ROAD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-3209
Mailing Address - Country:US
Mailing Address - Phone:865-687-7600
Mailing Address - Fax:865-687-7766
Practice Address - Street 1:115 GRESHAM RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37918-3209
Practice Address - Country:US
Practice Address - Phone:865-687-7600
Practice Address - Fax:865-687-7766
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000001403111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU79554Medicare UPIN