Basic Information
| Provider Information | |||||||||
| NPI: | 1598001307 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLNESS PHYSICAL THERAPY OF DIAMONDHEAD | ||||||||
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| OtherOrganizationName: | WELLNESS PT OF DIAMONDHEAD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1311 GAUSE BLVD | ||||||||
| Address2: | |||||||||
| City: | SLIDELL | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704583015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856496577 | ||||||||
| FaxNumber: | 9856497615 | ||||||||
| Practice Location | |||||||||
| Address1: | 1053 TINA LADNER VIC FAYE RD | ||||||||
| Address2: | |||||||||
| City: | PASS CHRISTIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395718920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856496577 | ||||||||
| FaxNumber: | 9856497615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2012 | ||||||||
| LastUpdateDate: | 12/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | MURRET | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | BRAD | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9856496577 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.