Healthcare Provider Details

I. General information

NPI: 1730546292
Provider Name (Legal Business Name): MATTHEW MATTOX P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2016
Last Update Date: 01/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 HIGHWAY 98 BYP
COLUMBIA MS
39429-3538
US

IV. Provider business mailing address

239 OLD HIGHWAY 24
FOXWORTH MS
39483-4840
US

V. Phone/Fax

Practice location:
  • Phone: 601-444-9200
  • Fax:
Mailing address:
  • Phone: 601-441-9942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT2003
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: