Healthcare Provider Details

I. General information

NPI: 1982257598
Provider Name (Legal Business Name): CAROLINE S BANKSTON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 BO BO DR
CRYSTAL SPRINGS MS
39059-2741
US

IV. Provider business mailing address

8205 PRESIDENTS DR
HUMMELSTOWN PA
17036-8621
US

V. Phone/Fax

Practice location:
  • Phone: 601-892-6330
  • Fax: 601-892-6331
Mailing address:
  • Phone: 717-839-2188
  • Fax: 717-565-1104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA6727
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: