Provider Demographics
NPI:1457446445
Name:ADVANCE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:ADVANCE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:662-843-4990
Mailing Address - Street 1:810 E SUNFLOWER RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732
Mailing Address - Country:US
Mailing Address - Phone:662-843-4990
Mailing Address - Fax:662-843-4954
Practice Address - Street 1:810 E SUNFLOWER RD
Practice Address - Street 2:SUITE 150
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732
Practice Address - Country:US
Practice Address - Phone:662-843-4990
Practice Address - Fax:662-843-4954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09385726Medicaid
MS09385726Medicaid