Healthcare Provider Details

I. General information

NPI: 1427115641
Provider Name (Legal Business Name): AQUATIC THERAPY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CARRIE MITCHELL RD
CARRIERE MS
39426
US

IV. Provider business mailing address

PO BOX 153
BUSH LA
70431-0153
US

V. Phone/Fax

Practice location:
  • Phone: 985-774-1155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT4166
License Number StateMS

VIII. Authorized Official

Name: DANA N ROSSER
Title or Position: MANAGER
Credential: PT
Phone: 985-774-1155