Provider Demographics
NPI:1851777692
Name:FALIS, JEFFREY
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:FALIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 GUDGER RD
Mailing Address - Street 2:
Mailing Address - City:SEWANEE
Mailing Address - State:TN
Mailing Address - Zip Code:37375-2896
Mailing Address - Country:US
Mailing Address - Phone:863-381-2410
Mailing Address - Fax:
Practice Address - Street 1:32 GUDGER RD
Practice Address - Street 2:
Practice Address - City:SEWANEE
Practice Address - State:TN
Practice Address - Zip Code:37375-2896
Practice Address - Country:US
Practice Address - Phone:863-381-2410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL39002255A2300X
TN18792255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000016578OtherBOC
FLAL 3900OtherLAT FL
TN1879OtherLAT TN
62983OtherNATA