Provider Demographics
NPI:1851448708
Name:CUSTOMIZED PHYSICAL THERAPY
Entity Type:Organization
Organization Name:CUSTOMIZED PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:M
Authorized Official - Last Name:RIMES
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:601-408-8700
Mailing Address - Street 1:702 HILLENDALE DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-2618
Mailing Address - Country:US
Mailing Address - Phone:601-408-8700
Mailing Address - Fax:601-264-2285
Practice Address - Street 1:103 FOX CHASE DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-2575
Practice Address - Country:US
Practice Address - Phone:601-408-8700
Practice Address - Fax:601-264-2285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT 1137261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSPT 1137OtherPHYSICAL THERAPY