Provider Demographics
NPI:1649218140
Name:PHYSICAL THERAPY OF DYERSBURG PC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY OF DYERSBURG PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:PRESLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:731-285-6600
Mailing Address - Street 1:2265 PARR AVE
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-2078
Mailing Address - Country:US
Mailing Address - Phone:731-285-6600
Mailing Address - Fax:731-285-8005
Practice Address - Street 1:2265 PARR AVE
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-2078
Practice Address - Country:US
Practice Address - Phone:731-285-6600
Practice Address - Fax:731-285-8005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000005425225100000X
TNPT0000006115225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3728055Medicaid
TN3728055Medicare ID - Type Unspecified