Provider Demographics
NPI:1811109457
Name:BELHAVEN PHYSICAL THERAPY CLINIC, LLC
Entity type:Organization
Organization Name:BELHAVEN PHYSICAL THERAPY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BELCHER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:601-355-9624
Mailing Address - Street 1:1054 GREYMONT AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2718
Mailing Address - Country:US
Mailing Address - Phone:601-355-9624
Mailing Address - Fax:601-353-6151
Practice Address - Street 1:1054 GREYMONT AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2718
Practice Address - Country:US
Practice Address - Phone:601-355-9624
Practice Address - Fax:601-353-6151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT2289261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSPT2289OtherPROVIDER NUMBER