Healthcare Provider Details

I. General information

NPI: 1992390264
Provider Name (Legal Business Name): PEYTON JEFFERSON WILLOUGHBY DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2021
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 HIGHPOINTE DR
BRANDON MS
39042-3169
US

IV. Provider business mailing address

1200 CORPORATE DRIVE SUITE 400
BIRMINGHAM AL
35242
US

V. Phone/Fax

Practice location:
  • Phone: 601-724-7310
  • Fax: 601-724-7311
Mailing address:
  • Phone: 423-206-4158
  • Fax: 717-773-4654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT7056
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: