Provider Demographics
NPI:1881986453
Name:GAILES, KEN J (PT)
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:J
Last Name:GAILES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 W CAMPBELL AVE
Mailing Address - Street 2:APT 1119
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-2998
Mailing Address - Country:US
Mailing Address - Phone:601-624-0350
Mailing Address - Fax:601-661-8457
Practice Address - Street 1:117 EAST AVE S
Practice Address - Street 2:
Practice Address - City:HOLLANDALE
Practice Address - State:MS
Practice Address - Zip Code:38748-3811
Practice Address - Country:US
Practice Address - Phone:601-624-0350
Practice Address - Fax:601-661-8457
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-13
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MSPT3460225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist