Provider Demographics
NPI:1174855464
Name:REGGIE WHITE CARDIO-PULMONARY REHABILITATION CENTER LLC
Entity Type:Organization
Organization Name:REGGIE WHITE CARDIO-PULMONARY REHABILITATION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:EVIN
Authorized Official - Last Name:DENMAN
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:901-246-0767
Mailing Address - Street 1:7600 AIRWAYS BLVD
Mailing Address - Street 2:SUITE G
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5138
Mailing Address - Country:US
Mailing Address - Phone:662-349-9802
Mailing Address - Fax:
Practice Address - Street 1:7420 GUTHRIE DR N
Practice Address - Street 2:STE. 108
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5876
Practice Address - Country:US
Practice Address - Phone:662-349-9802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251C2600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistCardiopulmonaryGroup - Multi-Specialty