1134135833 NPI number — GENESIS PHYSICAL THERAPY & REHABILITATION LLC

Table of content: (NPI 1134135833)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134135833 NPI number — GENESIS PHYSICAL THERAPY & REHABILITATION LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENESIS PHYSICAL THERAPY & REHABILITATION LLC
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:
6
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:
1134135833
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
290 E LAYFAIR DR
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
FLOWOOD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39232-9526
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-983-1200
Provider Business Mailing Address Fax Number:
601-983-1205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
290 E LAYFAIR DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
FLOWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39232-9526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-983-1200
Provider Business Practice Location Address Fax Number:
601-983-1205
Provider Enumeration Date:
08/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WHITLEY
Authorized Official First Name:
CLARENCE
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
C.O.O.
Authorized Official Telephone Number:
601-898-7527

Provider Taxonomy Codes

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

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

  • Identifier: 888588 . This is a "COVENTRY" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 232105700 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1058189 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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