Provider Demographics
NPI:1457006694
Name:SOLED OUT PERFORMANCE & PHYSICAL THERAPY
Entity Type:Organization
Organization Name:SOLED OUT PERFORMANCE & PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MACKENZIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:919-288-4386
Mailing Address - Street 1:2515 WILMA RUDOLPH BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5824
Mailing Address - Country:US
Mailing Address - Phone:931-436-5776
Mailing Address - Fax:
Practice Address - Street 1:2515 WILMA RUDOLPH BLVD STE 105
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5824
Practice Address - Country:US
Practice Address - Phone:931-436-9776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-16
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty