Provider Demographics
NPI:1346863651
Name:BAGWELL, JAMES BRANDON
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:BRANDON
Last Name:BAGWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2780 HIGHWAY 31 W
Mailing Address - Street 2:
Mailing Address - City:WHITE HOUSE
Mailing Address - State:TN
Mailing Address - Zip Code:37188-8967
Mailing Address - Country:US
Mailing Address - Phone:615-517-0081
Mailing Address - Fax:
Practice Address - Street 1:2780 HIGHWAY 31 W
Practice Address - Street 2:
Practice Address - City:WHITE HOUSE
Practice Address - State:TN
Practice Address - Zip Code:37188-8967
Practice Address - Country:US
Practice Address - Phone:615-517-0081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000013185225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist