Provider Demographics
NPI:1871810093
Name:MAX POTENTIAL REHAB INC
Entity type:Organization
Organization Name:MAX POTENTIAL REHAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:BS, AS, PTA
Authorized Official - Phone:865-776-8761
Mailing Address - Street 1:7905 CODY LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37938-3172
Mailing Address - Country:US
Mailing Address - Phone:865-776-8761
Mailing Address - Fax:
Practice Address - Street 1:7905 CODY LN
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37938-3172
Practice Address - Country:US
Practice Address - Phone:865-776-8761
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-27
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3409302F00000X, 302R00000X, 305R00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No302F00000XManaged Care OrganizationsExclusive Provider Organization
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0000001518Medicaid
TN0000001518Medicaid
0000001518Medicare Oscar/Certification
TN0000001518Medicare NSC
0000001518Medicare UPIN