Provider Demographics
NPI:1801370929
Name:SOUTHERN PHYSICAL THERAPY CLINIC, INC.
Entity Type:Organization
Organization Name:SOUTHERN PHYSICAL THERAPY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:ROBIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:769-242-2626
Mailing Address - Street 1:1620 HIGHWAY 11 N STE C
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-2070
Mailing Address - Country:US
Mailing Address - Phone:769-242-2626
Mailing Address - Fax:769-242-2685
Practice Address - Street 1:1620 HIGHWAY 11 N STE C
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-2070
Practice Address - Country:US
Practice Address - Phone:769-242-2626
Practice Address - Fax:769-242-2685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-25
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty