Provider Demographics
NPI:1952338667
Name:CLARKSDALE PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:CLARKSDALE PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/ TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:WINDHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-473-3400
Mailing Address - Street 1:50 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATER VALLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38965-2946
Mailing Address - Country:US
Mailing Address - Phone:662-473-3400
Mailing Address - Fax:662-473-4389
Practice Address - Street 1:100 EAST LEE
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614
Practice Address - Country:US
Practice Address - Phone:662-627-6734
Practice Address - Fax:662-627-6737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2010-12-02
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
MS09015818Medicaid
MSC03365Medicare ID - Type Unspecified