Healthcare Provider Details

I. General information

NPI: 1700831666
Provider Name (Legal Business Name): EASTERN SHORE PHYSICAL THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6475 VAN BUREN ST SUITE 102
DAPHNE AL
36526-7585
US

IV. Provider business mailing address

PO BOX 2463
DAPHNE AL
36526-2463
US

V. Phone/Fax

Practice location:
  • Phone: 251-626-9052
  • Fax: 251-626-5384
Mailing address:
  • Phone: 251-626-9052
  • Fax: 251-626-5384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPTH847
License Number StateAL

VIII. Authorized Official

Name: MCKENZIE JONES
Title or Position: CO-OWNER/PRESIDENT
Credential: DPT
Phone: 251-626-9052