Provider Demographics
NPI:1407847478
Name:FUNCTIONAL THERAPY CENTER, INC.
Entity Type:Organization
Organization Name:FUNCTIONAL THERAPY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NIKOLAS
Authorized Official - Middle Name:DOYLE
Authorized Official - Last Name:CARNATHAN
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:662-844-4471
Mailing Address - Street 1:499 GLOSTER CREEK VLG
Mailing Address - Street 2:SUITE I-3
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4600
Mailing Address - Country:US
Mailing Address - Phone:662-844-4471
Mailing Address - Fax:662-844-4472
Practice Address - Street 1:499 GLOSTER CREEK VLG
Practice Address - Street 2:SUITE I-3
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4600
Practice Address - Country:US
Practice Address - Phone:662-844-4471
Practice Address - Fax:662-844-4472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00304504Medicaid
MSC03282Medicare ID - Type UnspecifiedMEDICARE CLINIC CODE