Basic Information
| Provider Information | |||||||||
| NPI: | 1598134967 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DRAYER PHYSICAL THERAPY JACKSON LLC | ||||||||
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| OtherOrganizationName: | PERFORMANCE REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1220 N SHORE PKWY | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BRANDON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390476383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018290505 | ||||||||
| FaxNumber: | 6018290506 | ||||||||
| Practice Location | |||||||||
| Address1: | 1220 N SHORE PKWY | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BRANDON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390476383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018290505 | ||||||||
| FaxNumber: | 6018290506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2015 | ||||||||
| LastUpdateDate: | 09/16/2015 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 7172202100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.