Provider Demographics
NPI:1881778595
Name:WELLNESSWORKS OF CROSBY MEMORIAL HOSPITAL, LLC
Entity type:Organization
Organization Name:WELLNESSWORKS OF CROSBY MEMORIAL HOSPITAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:E
Authorized Official - Last Name:CHESHIRE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:601-749-2227
Mailing Address - Street 1:104 STREET A
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-5466
Mailing Address - Country:US
Mailing Address - Phone:601-749-2227
Mailing Address - Fax:601-749-2241
Practice Address - Street 1:104 STREET A
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-5466
Practice Address - Country:US
Practice Address - Phone:601-749-2227
Practice Address - Fax:601-749-2241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC03312Medicare ID - Type UnspecifiedMEDICARE GROUP