Provider Demographics
NPI:1134135833
Name:GENESIS PHYSICAL THERAPY & REHABILITATION LLC
Entity Type:Organization
Organization Name:GENESIS PHYSICAL THERAPY & REHABILITATION LLC
Other - Org Name:GENESIS PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.O.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:WHITLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-898-7527
Mailing Address - Street 1:290 E LAYFAIR DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9526
Mailing Address - Country:US
Mailing Address - Phone:601-983-1200
Mailing Address - Fax:601-983-1205
Practice Address - Street 1:290 E LAYFAIR DR
Practice Address - Street 2:SUITE B
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9526
Practice Address - Country:US
Practice Address - Phone:601-983-1200
Practice Address - Fax:601-983-1205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS888588OtherCOVENTRY
MS232105700OtherUS DEPT OF LABOR
MS1058189OtherUNITED HEALTH CARE
MS888588OtherCOVENTRY