Provider Demographics
NPI:1952339491
Name:NEW LIFE PHYSICAL THERAPY CENTER LLC
Entity type:Organization
Organization Name:NEW LIFE PHYSICAL THERAPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ABRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-876-4429
Mailing Address - Street 1:4832 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:TYLERTOWN
Mailing Address - State:MS
Mailing Address - Zip Code:39667-9221
Mailing Address - Country:US
Mailing Address - Phone:601-876-4429
Mailing Address - Fax:601-876-4422
Practice Address - Street 1:4832 PLAZA DR
Practice Address - Street 2:
Practice Address - City:TYLERTOWN
Practice Address - State:MS
Practice Address - Zip Code:39667-9221
Practice Address - Country:US
Practice Address - Phone:601-876-4429
Practice Address - Fax:601-876-4422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA35833481K261QP2000X
LA5745260001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5745260001Medicare NSC
5CP16Medicare ID - Type Unspecified