Provider Demographics
NPI:1629579685
Name:EIDSMOE, JUSTIN (DPT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:EIDSMOE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 CRESCENT CENTRE DR STE 300
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-7285
Mailing Address - Country:US
Mailing Address - Phone:615-416-0199
Mailing Address - Fax:
Practice Address - Street 1:1241 PT MALLARD PKWY STE 201
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-6555
Practice Address - Country:US
Practice Address - Phone:256-350-9750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH8822225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist