1801370929 NPI number — SOUTHERN PHYSICAL THERAPY CLINIC, INC.

Table of content: (NPI 1801370929)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801370929 NPI number — SOUTHERN PHYSICAL THERAPY CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN PHYSICAL THERAPY CLINIC, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801370929
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1620 HIGHWAY 11 N STE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PICAYUNE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39466-2070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
769-242-2626
Provider Business Mailing Address Fax Number:
769-242-2685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1620 HIGHWAY 11 N STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PICAYUNE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39466-2070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
769-242-2626
Provider Business Practice Location Address Fax Number:
769-242-2685
Provider Enumeration Date:
09/25/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROBIN
Authorized Official First Name:
ADAM
Authorized Official Middle Name:
LOUIS
Authorized Official Title or Position:
PHYSICAL THERAPIST
Authorized Official Telephone Number:
769-242-2626

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)