Provider Demographics
NPI:1891246286
Name:FORTINBERRY PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:FORTINBERRY PHYSICAL THERAPY LLC
Other - Org Name:FORTINBERRY PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTINBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:601-248-8019
Mailing Address - Street 1:PO BOX 1358
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:MS
Mailing Address - Zip Code:39666-1301
Mailing Address - Country:US
Mailing Address - Phone:601-276-2200
Mailing Address - Fax:601-276-3300
Practice Address - Street 1:709 ROBB STREET
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:MS
Practice Address - Zip Code:39666
Practice Address - Country:US
Practice Address - Phone:601-248-8019
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-20
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT2344225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty