Provider Demographics
NPI:1154626497
Name:TEAM 82 PHYSICAL THERAPY
Entity Type:Organization
Organization Name:TEAM 82 PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:601-497-1200
Mailing Address - Street 1:PO BOX 16153
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39236-6153
Mailing Address - Country:US
Mailing Address - Phone:601-951-9760
Mailing Address - Fax:
Practice Address - Street 1:1198 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4701
Practice Address - Country:US
Practice Address - Phone:601-951-9760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty