Basic Information
| Provider Information | |||||||||
| NPI: | 1427620814 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BREEDLOVE | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | JACKSON | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10133 SHERRILL BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379323347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885312204 | ||||||||
| FaxNumber: | 8552328604 | ||||||||
| Practice Location | |||||||||
| Address1: | 10133 SHERRILL BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379323347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885312204 | ||||||||
| FaxNumber: | 8552328604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2021 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA004344 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.