Provider Demographics
NPI:1942381207
Name:BANYAN HEALTHCARE & WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:BANYAN HEALTHCARE & WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-943-9294
Mailing Address - Street 1:1030 MCARTHUR ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-2453
Mailing Address - Country:US
Mailing Address - Phone:931-723-7950
Mailing Address - Fax:931-723-7815
Practice Address - Street 1:1030 MCARTHUR ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-2453
Practice Address - Country:US
Practice Address - Phone:931-723-7950
Practice Address - Fax:931-723-7815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3736645Medicare PIN