Provider Demographics
NPI:1457371718
Name:BOUCHER, JOHN R (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 W BADDOUR PKWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-2656
Mailing Address - Country:US
Mailing Address - Phone:615-453-1422
Mailing Address - Fax:615-453-1429
Practice Address - Street 1:1430 W BADDOUR PKWY
Practice Address - Street 2:SUITE C
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-2656
Practice Address - Country:US
Practice Address - Phone:615-453-1422
Practice Address - Fax:615-453-1429
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN05269225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN05269OtherPHYSICAL THERAPY LICENSE