Provider Demographics
NPI:1316027261
Name:PHILLIP L & CHARLOTTE C DENNISON PTRS
Entity Type:Organization
Organization Name:PHILLIP L & CHARLOTTE C DENNISON PTRS
Other - Org Name:SCOOTER UNLIMITED, JACKSON MEDICAL SUPPLY, LYMPHEDEMA TREATMENT COMPAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:L
Authorized Official - Last Name:DENNISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-664-7879
Mailing Address - Street 1:110 CARRIAGE HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3938
Mailing Address - Country:US
Mailing Address - Phone:731-664-7879
Mailing Address - Fax:731-664-7810
Practice Address - Street 1:110 CARRIAGE HOUSE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3938
Practice Address - Country:US
Practice Address - Phone:731-664-7879
Practice Address - Fax:731-664-7810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1454677Medicaid
TN4083665OtherBCBS
TN1083330001Medicare ID - Type UnspecifiedPROVIDER