Provider Demographics
NPI:1649228230
Name:PRUMBS, MICHAEL (LPO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PRUMBS
Suffix:
Gender:M
Credentials:LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2408 FORT HENRY DR
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-3708
Mailing Address - Country:US
Mailing Address - Phone:423-246-7272
Mailing Address - Fax:423-246-2803
Practice Address - Street 1:2408 FORT HENRY DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664-3708
Practice Address - Country:US
Practice Address - Phone:423-246-7272
Practice Address - Fax:423-246-2803
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNORT16222Z00000X
TNPRO16224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1454327Medicaid
TN1454327Medicaid