Provider Demographics
NPI:1881930337
Name:CUMBERLAND CHIROPRACTIC AND SPORTS MEDICINE, LLC
Entity type:Organization
Organization Name:CUMBERLAND CHIROPRACTIC AND SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:615-444-2234
Mailing Address - Street 1:1633 W MAIN ST
Mailing Address - Street 2:#401
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-3423
Mailing Address - Country:US
Mailing Address - Phone:615-444-2234
Mailing Address - Fax:615-547-4849
Practice Address - Street 1:1633 W MAIN ST
Practice Address - Street 2:#401
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-3423
Practice Address - Country:US
Practice Address - Phone:615-444-2234
Practice Address - Fax:615-547-4849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-02
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN2103111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3974016Medicare PIN