Provider Demographics
NPI:1427507201
Name:ADVANCED PHYSIOTHERAPY, PLLC
Entity type:Organization
Organization Name:ADVANCED PHYSIOTHERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER- PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DREW
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, OCS
Authorized Official - Phone:931-319-2763
Mailing Address - Street 1:705 E HUDGENS ST APT A
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-4564
Mailing Address - Country:US
Mailing Address - Phone:931-403-2040
Mailing Address - Fax:931-403-2041
Practice Address - Street 1:4120 BRADFORD HICKS DR
Practice Address - Street 2:SUITE A
Practice Address - City:LIVINGSTON
Practice Address - State:TN
Practice Address - Zip Code:38570-2213
Practice Address - Country:US
Practice Address - Phone:931-403-2040
Practice Address - Fax:931-403-2041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-22
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8634261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN01379040Medicaid
TN01379040Medicaid