Provider Demographics
NPI:1700831666
Name:EASTERN SHORE PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:EASTERN SHORE PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MCKENZIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:251-626-9052
Mailing Address - Street 1:PO BOX 2463
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-2463
Mailing Address - Country:US
Mailing Address - Phone:251-626-9052
Mailing Address - Fax:251-626-5384
Practice Address - Street 1:6475 VAN BUREN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-7585
Practice Address - Country:US
Practice Address - Phone:251-626-9052
Practice Address - Fax:251-626-5384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH847261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALCL2210OtherRAIL ROAL MEDICARE
ALD319Medicare PIN