Provider Demographics
NPI:1669528436
Name:CHEATHAM, MARY GAIL R (DC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:GAIL R
Last Name:CHEATHAM
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:GAIL R
Other - Last Name:CHEATHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1450 SAM DAVIS RD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167
Mailing Address - Country:US
Mailing Address - Phone:615-459-0100
Mailing Address - Fax:615-355-4212
Practice Address - Street 1:1450 SAM DAVIS RD
Practice Address - Street 2:SUITE 170
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167
Practice Address - Country:US
Practice Address - Phone:615-459-0100
Practice Address - Fax:615-355-4212
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN632111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0087779OtherBCBS OF TN
TN0087779OtherBCBS OF TN
T81710Medicare UPIN