Provider Demographics
NPI:1528582046
Name:THEURAPEUTICS
Entity Type:Organization
Organization Name:THEURAPEUTICS
Other - Org Name:THERAPEUTICS L.M.T
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:TANIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-616-7601
Mailing Address - Street 1:200 STONEBRIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-6028
Mailing Address - Country:US
Mailing Address - Phone:731-616-7601
Mailing Address - Fax:
Practice Address - Street 1:4 N HAMPTON LN
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3924
Practice Address - Country:US
Practice Address - Phone:731-616-7601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6345302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
822301735OtherEIN NUMBER