Provider Demographics
NPI:1093796054
Name:VANCE, MARK S (DPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:VANCE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 681478
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-1478
Mailing Address - Country:US
Mailing Address - Phone:615-591-6590
Mailing Address - Fax:615-591-6601
Practice Address - Street 1:491 SAGE RD N
Practice Address - Street 2:STE. 1000
Practice Address - City:WHITE HOUSE
Practice Address - State:TN
Practice Address - Zip Code:37188-9360
Practice Address - Country:US
Practice Address - Phone:615-672-8230
Practice Address - Fax:615-672-8977
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10379225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000048012OtherANTHEM
KY3827598001OtherCIGNA
KYR40140Medicare UPIN
KY650008056Medicare PIN
KY0657701Medicare PIN
KY0567804Medicare PIN
KY5004801Medicare PIN