Provider Demographics
NPI:1760502520
Name:SOUTHERN REHAB & AQUATICS
Entity Type:Organization
Organization Name:SOUTHERN REHAB & AQUATICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT
Authorized Official - Prefix:MR
Authorized Official - First Name:TRACE
Authorized Official - Middle Name:DEWAYNE
Authorized Official - Last Name:KENNEMORE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:423-837-7536
Mailing Address - Street 1:400 DIXIE LEE CENTER RD
Mailing Address - Street 2:
Mailing Address - City:KIMBALL
Mailing Address - State:TN
Mailing Address - Zip Code:37347-5672
Mailing Address - Country:US
Mailing Address - Phone:423-837-7536
Mailing Address - Fax:423-837-7538
Practice Address - Street 1:400 DIXIE LEE CENTER RD
Practice Address - Street 2:SUITE A
Practice Address - City:KIMBALL
Practice Address - State:TN
Practice Address - Zip Code:37347-5672
Practice Address - Country:US
Practice Address - Phone:423-837-7536
Practice Address - Fax:423-837-7538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000006009225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3732180Medicare ID - Type Unspecified