Provider Demographics
NPI:1891117420
Name:MADISON HEALTHPLEX & SPORTS PERFORMANCE CENTER LLC
Entity Type:Organization
Organization Name:MADISON HEALTHPLEX & SPORTS PERFORMANCE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRISSETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:6019-441-7172
Mailing Address - Street 1:501 BAPTIST DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-2026
Mailing Address - Country:US
Mailing Address - Phone:601-944-1717
Mailing Address - Fax:601-944-9780
Practice Address - Street 1:501 BAPTIST DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-2026
Practice Address - Country:US
Practice Address - Phone:601-944-1717
Practice Address - Fax:601-944-9780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-16
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty