Provider Demographics
NPI:1710654686
Name:MISSISSIPPI SPINE AND PELVIC HEALTH PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:MISSISSIPPI SPINE AND PELVIC HEALTH PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/COO
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:BROOKS
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-935-0766
Mailing Address - Street 1:1107 HIGHLAND COLONY PKWY STE 109
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-6079
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1107 HIGHLAND COLONY PKWY STE 109
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-6079
Practice Address - Country:US
Practice Address - Phone:601-935-0766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-26
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy