NPIMap

Organization Active NPI

904 Therapy LLC

  • Physical Therapy Clinic/Center
  • Rogersville, TN
National Provider Identifier
1467193102
Registry record updated Apr 6, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical Therapy Clinic/CenterTaxonomy code 261QP2000X
Legal business name
904 THERAPY LLC
Practice address
900 W Main St
Rogersville, TN 37857-2448
Phone
(423) 500-5600
Fax
(423) 373-1351
NPI assigned
Apr 6, 2022
Last updated
Apr 6, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 6, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jordan C Blcak
Title
President
Phone
(423) 258-2264

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapy Clinic/Center 261QP2000X Primary

Addresses

Primary practice location

900 W Main St
Rogersville, TN 37857-2448

Mailing address

2800 N 6TH St Unit 1
Saint Augustine, FL 32084-1886
Phone (423) 317-7772

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL promptemr.com Jordan C Black

National Provider Directory

National Provider Directory

Locations

2800 N 6th St
Unit 1
St Augustine, FL 32084
Phone (904) 300-0886

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1649203200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1649203200000",
    "number": "1467193102",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2800 N 6TH ST UNIT 1",
            "city": "SAINT AUGUSTINE",
            "state": "FL",
            "postal_code": "320841886",
            "telephone_number": "423-317-7772",
            "fax_number": "423-373-1351"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "900 W MAIN ST",
            "city": "ROGERSVILLE",
            "state": "TN",
            "postal_code": "378572448",
            "telephone_number": "423-500-5600",
            "fax_number": "423-373-1351"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "904 THERAPY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-04-06",
        "last_updated": "2022-04-06",
        "certification_date": "2022-04-06",
        "status": "A",
        "authorized_official_last_name": "BLCAK",
        "authorized_official_first_name": "JORDAN",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "423-258-2264"
    },
    "taxonomies": [
        {
            "code": "261QP2000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Physical Therapy",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "promptemr.com",
            "affiliation": "Y",
            "affiliationName": "Jordan C Black",
            "address_1": "900 W Main St",
            "city": "Rogersville",
            "state": "TN",
            "country_code": "US",
            "postal_code": "378572448",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Rogersville, TN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 6, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.