Provider Demographics
NPI:1629343124
Name:PRO PT
Entity Type:Organization
Organization Name:PRO PT
Other - Org Name:PRO THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:LPTA
Authorized Official - Phone:662-231-0280
Mailing Address - Street 1:PO BOX 205
Mailing Address - Street 2:
Mailing Address - City:MANTACHIE
Mailing Address - State:MS
Mailing Address - Zip Code:38855-0205
Mailing Address - Country:US
Mailing Address - Phone:662-282-4949
Mailing Address - Fax:662-282-4955
Practice Address - Street 1:3077 HIGHWAY 371 N
Practice Address - Street 2:
Practice Address - City:MANTACHIE
Practice Address - State:MS
Practice Address - Zip Code:38855-7274
Practice Address - Country:US
Practice Address - Phone:662-282-4949
Practice Address - Fax:662-282-4955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-15
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08130311Medicaid
MS08130311Medicaid