Provider Demographics
NPI:1093875866
Name:RESTORE PHYSICAL THERAPY INC.
Entity Type:Organization
Organization Name:RESTORE PHYSICAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:RAYBORN
Authorized Official - Suffix:IV
Authorized Official - Credentials:PT
Authorized Official - Phone:601-765-2900
Mailing Address - Street 1:10 MELODY LN
Mailing Address - Street 2:
Mailing Address - City:COLLINS
Mailing Address - State:MS
Mailing Address - Zip Code:39428-9002
Mailing Address - Country:US
Mailing Address - Phone:601-765-2900
Mailing Address - Fax:601-765-2903
Practice Address - Street 1:10 MELODY LN
Practice Address - Street 2:
Practice Address - City:COLLINS
Practice Address - State:MS
Practice Address - Zip Code:39428-9002
Practice Address - Country:US
Practice Address - Phone:601-765-2900
Practice Address - Fax:601-765-2903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSAPPLYING FORMedicare ID - Type UnspecifiedMEDICARE PART B - PENDING