MEDICARE: PROACTIVE PHYSICAL THERAPY LLC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1538969795
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROACTIVE PHYSICAL THERAPY LLC.

Provider Business Mailing Address
First Line	:	701 ANTHONY ST
Second Line	:
City	:	PORT GIBSON
State	:	MS
Zip	:	39150-2053
Country	:	US
Telephone Number	:	601-994-3548
Fax Number	:	601-448-0234

Provider Business Practice Location Address
First Line	:	701 ANTHONY ST
Second Line	:
City	:	PORT GIBSON
State	:	MS
Zip	:	39150-2053
Country	:	US
Telephone Number	:	601-218-5004
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KENDRIQUE AKEEM MORGAN
Credential	:	DPT
Telephone Number	:	601-218-5004

Provider Enumeration Date	:	03/17/2025
Last Update Date	:	01/05/2026

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