Basic Information
Provider Information | |||||||||
NPI: | 1932645843 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DRAYER PHYSICAL THERAPY MISSISSIPPI LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2416 HIGHWAY 45 N | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | MS | ||||||||
PostalCode: | 397051320 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6623276705 | ||||||||
FaxNumber: | 6623276760 | ||||||||
Practice Location | |||||||||
Address1: | 339 W THIRD ST | ||||||||
Address2: |   | ||||||||
City: | FOREST | ||||||||
State: | MS | ||||||||
PostalCode: | 390744107 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6012878007 | ||||||||
FaxNumber: | 6012878038 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2017 | ||||||||
LastUpdateDate: | 01/17/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WILLIAMS | ||||||||
AuthorizedOfficialFirstName: | ERIC | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
AuthorizedOfficialTelephone: | 7172202100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
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AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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.