Provider Demographics
NPI:1376713701
Name:TENNESSEE PODIATRY LLC
Entity Type:Organization
Organization Name:TENNESSEE PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:BREEDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:615-369-6500
Mailing Address - Street 1:PO BOX 331283
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203
Mailing Address - Country:US
Mailing Address - Phone:615-369-6500
Mailing Address - Fax:
Practice Address - Street 1:139 WILLIAMSBURGH WEST CT
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37221-2609
Practice Address - Country:US
Practice Address - Phone:615-369-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0570261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3353846Medicaid
TNU82677Medicare UPIN
TN3353846Medicare PIN