Provider Demographics
NPI:1326133455
Name:SCOTT'S FAMILY FITNESS & PHYSICAL THERAPY
Entity Type:Organization
Organization Name:SCOTT'S FAMILY FITNESS & PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CONNY
Authorized Official - Middle Name:CHRISTL
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-731-1140
Mailing Address - Street 1:PO BOX 429
Mailing Address - Street 2:808 HWY 98 BYPASS
Mailing Address - City:COLUMBIA
Mailing Address - State:MS
Mailing Address - Zip Code:39429-0429
Mailing Address - Country:US
Mailing Address - Phone:601-731-1140
Mailing Address - Fax:601-731-1148
Practice Address - Street 1:808 HWY 98 BYPASS
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-0429
Practice Address - Country:US
Practice Address - Phone:601-731-1140
Practice Address - Fax:601-731-1148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121739Medicaid
MSS81273Medicare UPIN