Provider Demographics
NPI:1295817153
Name:PICAYUNE PHYSICAL THERAPY CENTER
Entity Type:Organization
Organization Name:PICAYUNE PHYSICAL THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:601-749-8146
Mailing Address - Street 1:220 S CURRAN AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-4524
Mailing Address - Country:US
Mailing Address - Phone:601-749-8146
Mailing Address - Fax:601-749-8147
Practice Address - Street 1:220 S CURRAN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-4524
Practice Address - Country:US
Practice Address - Phone:601-749-8146
Practice Address - Fax:601-749-8147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT357225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC03106Medicare ID - Type UnspecifiedGROUP