Basic Information
| Provider Information | |||||||||
| NPI: | 1952472219 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSISSIPPI SPORT AND SPINE REHABILITATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1743 CLIFF GOOKIN BLVD | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388016723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6626805216 | ||||||||
| FaxNumber: | 6626805217 | ||||||||
| Practice Location | |||||||||
| Address1: | 1743 CLIFF GOOKIN BLVD | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388016723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6626805216 | ||||||||
| FaxNumber: | 6626805217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2006 | ||||||||
| LastUpdateDate: | 10/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | BARKER | ||||||||
| AuthorizedOfficialFirstName: | CHAD | ||||||||
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| AuthorizedOfficialTitleorPosition: | ATHLETIC TRAINER | ||||||||
| AuthorizedOfficialTelephone: | 6626805216 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | AT | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 09015485 | 05 | MS | MEDICAID |