1528577392 NPI number — 2083 THERAPY, LLC

Table of content: (NPI 1528577392)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528577392 NPI number — 2083 THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
2083 THERAPY, 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:
1528577392
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 PIONEER WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAGEE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39111-5501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-849-6440
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
513 W MARION AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRYSTAL SPRINGS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39059-2748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-281-5930
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/25/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MCNULTY
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
601-849-6440

Provider Taxonomy Codes

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

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

  • Identifier: 1109164 . This is a "BUSINESS LICENSE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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