Provider Demographics
NPI:1336367135
Name:TRAIL BLAZIN THERAPY LLC
Entity Type:Organization
Organization Name:TRAIL BLAZIN THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER,MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RACHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENTON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:601-845-0876
Mailing Address - Street 1:260 BARNES RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MS
Mailing Address - Zip Code:39073-8066
Mailing Address - Country:US
Mailing Address - Phone:601-845-0876
Mailing Address - Fax:
Practice Address - Street 1:260 BARNES RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MS
Practice Address - Zip Code:39073-8066
Practice Address - Country:US
Practice Address - Phone:601-845-0876
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP.T.0978225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016256Medicaid
MS09016256Medicaid