Provider Demographics
NPI:1326530379
Name:RECORD, WILLIAM MICHAEL (PT, DPT, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MICHAEL
Last Name:RECORD
Suffix:
Gender:M
Credentials:PT, DPT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 CARTHAGE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-9438
Mailing Address - Country:US
Mailing Address - Phone:731-414-6961
Mailing Address - Fax:
Practice Address - Street 1:103 MAIN ST S
Practice Address - Street 2:
Practice Address - City:MC KENZIE
Practice Address - State:TN
Practice Address - Zip Code:38201-2200
Practice Address - Country:US
Practice Address - Phone:731-393-8000
Practice Address - Fax:731-393-8100
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11759225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist