Provider Demographics
NPI:1790078962
Name:BOOMERSHINE WELLNESS CENTERS, PLC
Entity Type:Organization
Organization Name:BOOMERSHINE WELLNESS CENTERS, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:BOOMERSHINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:615-435-3235
Mailing Address - Street 1:330 MALLORY STATION RD
Mailing Address - Street 2:SUITE E-15
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-2859
Mailing Address - Country:US
Mailing Address - Phone:615-435-3235
Mailing Address - Fax:615-435-3275
Practice Address - Street 1:330 MALLORY STATION RD
Practice Address - Street 2:SUITE E-15
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-2859
Practice Address - Country:US
Practice Address - Phone:615-435-3235
Practice Address - Fax:615-435-3275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-22
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38402207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNI14663Medicare UPIN