Provider Demographics
NPI:1710177829
Name:PROHEALTH PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PROHEALTH PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WISNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-997-9991
Mailing Address - Street 1:1102 DEKALB PLAZA BLVD SW
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35967-4868
Mailing Address - Country:US
Mailing Address - Phone:256-997-9991
Mailing Address - Fax:256-997-9950
Practice Address - Street 1:1102 DEKALB PLAZA BLVD SW
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35967-4868
Practice Address - Country:US
Practice Address - Phone:256-997-9991
Practice Address - Fax:256-997-9950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL=========OtherFEDERAL TAX ID