Basic Information
| Provider Information | |||||||||
| NPI: | 1174042360 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 2083 THERAPY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | 2083 THERAPY OF HAZELHURST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PIONEER WAY | ||||||||
| Address2: | |||||||||
| City: | MAGEE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391115501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018496440 | ||||||||
| FaxNumber: | 6018491332 | ||||||||
| Practice Location | |||||||||
| Address1: | 236 CALDWELL DR | ||||||||
| Address2: | |||||||||
| City: | HAZLEHURST | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390832723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018949004 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2017 | ||||||||
| LastUpdateDate: | 04/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCNULTY | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6018496440 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | IV | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 1109164 | 01 | MS | BUSINESS LICENSE | OTHER |