Provider Demographics
NPI:1417224635
Name:BUTNER, JOHN MATTHEW (BS)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MATTHEW
Last Name:BUTNER
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 MANDA STACY RD
Mailing Address - Street 2:
Mailing Address - City:DECHERD
Mailing Address - State:TN
Mailing Address - Zip Code:37324-4342
Mailing Address - Country:US
Mailing Address - Phone:931-703-2864
Mailing Address - Fax:
Practice Address - Street 1:1905 N JACKSON ST STE 930
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-8243
Practice Address - Country:US
Practice Address - Phone:931-461-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator