Basic Information
| Provider Information | |||||||||
| NPI: | 1316296072 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUGHES | ||||||||
| FirstName: | CALVIN | ||||||||
| MiddleName: | ALEXANDER | ||||||||
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| NameSuffix: | II | ||||||||
| Credential: | LPTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3255 NOTTINGHAM RD | ||||||||
| Address2: | |||||||||
| City: | OCEAN SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395644359 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 303 N HURSTBOURNE PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402225158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024125847 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2012 | ||||||||
| LastUpdateDate: | 09/09/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA4330 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 225200000X | 05 | MS | MEDICAID |