Provider Demographics
NPI:1821152877
Name:V A SOUTH
Entity Type:Organization
Organization Name:V A SOUTH
Other - Org Name:V A SOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:T
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:601-927-7671
Mailing Address - Street 1:PO BOX 3183
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39158-3183
Mailing Address - Country:US
Mailing Address - Phone:601-636-6019
Mailing Address - Fax:601-661-8457
Practice Address - Street 1:4304 HIGHWAY 80 W STE A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-5922
Practice Address - Country:US
Practice Address - Phone:601-636-6019
Practice Address - Fax:601-661-8457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3192225100000X
MSOT2019225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124552Medicaid
MS00124552Medicaid