1740500784 NPI number — READY, SET, GO THERAPY, LLC

Table of content: (NPI 1740500784)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740500784 NPI number — READY, SET, GO THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
READY, SET, GO 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:
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:
1740500784
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
311 N MAIN ST
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:
39466-3313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-799-4065
Provider Business Mailing Address Fax Number:
601-620-4117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 SECOND ST
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:
39466-4001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-799-4065
Provider Business Practice Location Address Fax Number:
601-799-4064
Provider Enumeration Date:
06/01/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KOCH
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OCCUPATIONAL THERAPIST
Authorized Official Telephone Number:
601-799-4065

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  OT2062 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00159232 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04273212 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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