Basic Information
| Provider Information | |||||||||
| NPI: | 1194237206 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXOS PHYSICAL THERAPY AND SPORTS MEDICINE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 BAY ST | ||||||||
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| City: | CLANTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350453000 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6542 GOODMAN RD | ||||||||
| Address2: | |||||||||
| City: | OLIVE BRANCH | ||||||||
| State: | MS | ||||||||
| PostalCode: | 38654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2052593991 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2017 | ||||||||
| LastUpdateDate: | 12/13/2018 | ||||||||
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| AuthorizedOfficialLastName: | PERRY | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2052593991 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.