Provider Demographics
NPI:1669054896
Name:ARNOLD, ALTRECE AFONDRE (PT)
Entity type:Individual
Prefix:
First Name:ALTRECE
Middle Name:AFONDRE
Last Name:ARNOLD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7620 OLD CANTON RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8968
Mailing Address - Country:US
Mailing Address - Phone:601-213-8194
Mailing Address - Fax:
Practice Address - Street 1:7620 OLD CANTON RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-8968
Practice Address - Country:US
Practice Address - Phone:601-213-8194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1101225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist