Provider Demographics
NPI:1952705386
Name:THERAPEUTIC HEALTH CLINIC
Entity Type:Organization
Organization Name:THERAPEUTIC HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M
Authorized Official - Prefix:MR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:TYSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-386-2534
Mailing Address - Street 1:2111 FERRY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-2961
Mailing Address - Country:US
Mailing Address - Phone:229-386-2534
Mailing Address - Fax:229-386-2534
Practice Address - Street 1:223 CENTRAL AVE N
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-4344
Practice Address - Country:US
Practice Address - Phone:229-387-7111
Practice Address - Fax:229-387-7111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1265734750OtherNPI
GA1245292291OtherNPI