Provider Demographics
NPI:1912001579
Name:GENESIS PHYSICAL THERAPY
Entity Type:Organization
Organization Name:GENESIS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:CHASSIETY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-372-1499
Mailing Address - Street 1:1777 ELLIS AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-3616
Mailing Address - Country:US
Mailing Address - Phone:601-372-1499
Mailing Address - Fax:601-372-9862
Practice Address - Street 1:1777 ELLIS AVE
Practice Address - Street 2:SUITE B
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3616
Practice Address - Country:US
Practice Address - Phone:601-372-1499
Practice Address - Fax:601-372-9862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty