Provider Demographics
NPI:1518400191
Name:FRANKLIN COUNTY MEMORIAL HOSPITAL DBA FC SPORTS AND THERAPY CENTER
Entity Type:Organization
Organization Name:FRANKLIN COUNTY MEMORIAL HOSPITAL DBA FC SPORTS AND THERAPY CENTER
Other - Org Name:FC SPORTS AND THERAPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLEWARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-384-8126
Mailing Address - Street 1:PO BOX 744
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39653-0744
Mailing Address - Country:US
Mailing Address - Phone:601-384-8179
Mailing Address - Fax:
Practice Address - Street 1:248 B MAIN ST W
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:MS
Practice Address - Zip Code:39653
Practice Address - Country:US
Practice Address - Phone:601-384-8179
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRANKLIN COUNTY MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-30
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation