Basic Information
| Provider Information | |||||||||
| NPI: | 1871258350 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIME PHYSICAL THERAPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7627 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366700627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516337211 | ||||||||
| FaxNumber: | 2514106079 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 ETOWAH INDUSTRIAL CT | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301148016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516337211 | ||||||||
| FaxNumber: | 2514106079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2021 | ||||||||
| LastUpdateDate: | 11/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2514457267 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 11/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.