Provider Demographics
NPI:1841215670
Name:PHYSICAL THERAPY CLINIC OF GULFPORT
Entity Type:Organization
Organization Name:PHYSICAL THERAPY CLINIC OF GULFPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST, OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:W
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:228-863-0200
Mailing Address - Street 1:3506 WASHINGTON AVE
Mailing Address - Street 2:STE. D
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-3103
Mailing Address - Country:US
Mailing Address - Phone:228-863-0200
Mailing Address - Fax:228-863-0809
Practice Address - Street 1:3506 WASHINGTON AVE
Practice Address - Street 2:STE. D
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3103
Practice Address - Country:US
Practice Address - Phone:228-863-0200
Practice Address - Fax:228-863-0809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT15742251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS650000187Medicare ID - Type Unspecified