Provider Demographics
NPI:1922377019
Name:LBA MEDICAL SERVICES LLC
Entity type:Organization
Organization Name:LBA MEDICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:423-775-0771
Mailing Address - Street 1:114 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:TN
Mailing Address - Zip Code:37321
Mailing Address - Country:US
Mailing Address - Phone:423-775-3336
Mailing Address - Fax:423-775-6052
Practice Address - Street 1:200 SANITARIUM CIRCLE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TN
Practice Address - Zip Code:37321
Practice Address - Country:US
Practice Address - Phone:423-775-0771
Practice Address - Fax:423-834-9059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-20
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOT000004463225X00000X
TNPT000008620225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty