Provider Demographics
NPI:1790800894
Name:GENESIS PHYSICAL THERAPY
Entity Type:Organization
Organization Name:GENESIS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLIFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-428-2004
Mailing Address - Street 1:1707 WEST 20TH STREET
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39442
Mailing Address - Country:US
Mailing Address - Phone:601-428-2004
Mailing Address - Fax:601-428-8833
Practice Address - Street 1:1707 WEST 20TH STREET
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39442
Practice Address - Country:US
Practice Address - Phone:601-428-2004
Practice Address - Fax:601-428-8833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0780225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty