Provider Demographics
NPI:1952498552
Name:GRENADA PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:GRENADA PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:HILL
Authorized Official - Suffix:II
Authorized Official - Credentials:PT
Authorized Official - Phone:662-227-9748
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38902-0278
Mailing Address - Country:US
Mailing Address - Phone:662-227-9748
Mailing Address - Fax:662-227-9769
Practice Address - Street 1:601 OLD HICKORY RD
Practice Address - Street 2:STE A
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4086
Practice Address - Country:US
Practice Address - Phone:662-227-9748
Practice Address - Fax:662-227-9769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT2219261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016043Medicaid
MS5946510001Medicare NSC
MS256585Medicare ID - Type UnspecifiedGROUP MEDICARE