Provider Demographics
NPI:1639393283
Name:PRIDMORE, KEVIN WAYNE (PT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:WAYNE
Last Name:PRIDMORE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
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Mailing Address - Street 1:5419 PORTERSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:TN
Mailing Address - Zip Code:38004-7331
Mailing Address - Country:US
Mailing Address - Phone:901-840-2359
Mailing Address - Fax:731-221-2255
Practice Address - Street 1:326 ASBURY AVE
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:TN
Practice Address - Zip Code:38063-5577
Practice Address - Country:US
Practice Address - Phone:731-221-2478
Practice Address - Fax:731-221-2255
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TN6702225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist