Provider Demographics
NPI:1265849228
Name:ADVANCED HEALTH AND WELLNESS CENTER OF NASHVILLE LLC
Entity Type:Organization
Organization Name:ADVANCED HEALTH AND WELLNESS CENTER OF NASHVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:BUPP
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:330-336-9500
Mailing Address - Street 1:201 GREAT OAKS TRL
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-9430
Mailing Address - Country:US
Mailing Address - Phone:330-336-9500
Mailing Address - Fax:
Practice Address - Street 1:2001 MALLORY LN
Practice Address - Street 2:SUITE 301
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-8233
Practice Address - Country:US
Practice Address - Phone:615-905-0120
Practice Address - Fax:615-778-2900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-22
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ010891Medicaid
TN103G702007Medicare PIN