Provider Demographics
NPI:1851978340
Name:PLAY FOR LIFE
Entity Type:Organization
Organization Name:PLAY FOR LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACI
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MOTR/L
Authorized Official - Phone:662-832-8017
Mailing Address - Street 1:2120 SEATON RD
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:MS
Mailing Address - Zip Code:39154-9249
Mailing Address - Country:US
Mailing Address - Phone:662-832-8017
Mailing Address - Fax:844-308-8878
Practice Address - Street 1:2120 SEATON RD
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:MS
Practice Address - Zip Code:39154-9249
Practice Address - Country:US
Practice Address - Phone:662-832-8017
Practice Address - Fax:844-308-8878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-29
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06787256Medicaid