Provider Demographics
NPI:1972028520
Name:FLINT CREEK PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:FLINT CREEK PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:601-528-1994
Mailing Address - Street 1:321 FLORA GENE AVE W STE D
Mailing Address - Street 2:
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39577-5008
Mailing Address - Country:US
Mailing Address - Phone:601-528-1994
Mailing Address - Fax:601-528-1995
Practice Address - Street 1:321 FLORA GENE AVE W STE D
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-5008
Practice Address - Country:US
Practice Address - Phone:601-523-1994
Practice Address - Fax:601-523-1995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4487261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06070264Medicaid