Provider Demographics
NPI:1568537363
Name:EAST TENNESSEE COMPREHENSIVE REHABILITATION CENTER INC
Entity Type:Organization
Organization Name:EAST TENNESSEE COMPREHENSIVE REHABILITATION CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BOYD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MINNICH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:423-586-6866
Mailing Address - Street 1:420 W MORRIS BLVD
Mailing Address - Street 2:STE 180
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37813
Mailing Address - Country:US
Mailing Address - Phone:423-586-6866
Mailing Address - Fax:423-581-9679
Practice Address - Street 1:420 W MORRIS BLVD
Practice Address - Street 2:STE 180
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37813
Practice Address - Country:US
Practice Address - Phone:423-586-6866
Practice Address - Fax:423-581-9679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000751225100000X
2169225100000X
TN5471225100000X
TN2734225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3651836PTMedicaid
TN3655603OTMedicaid
TNCL2481OtherRAIL ROAD MEDICARE
3651836PTMedicare ID - Type UnspecifiedGRP
3655603OTMedicare ID - Type UnspecifiedGRP