Healthcare Provider Details

I. General information

NPI: 1730635087
Provider Name (Legal Business Name): ELITE PHYSICAL THERAPY AND WELLNESS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 03/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 7TH ST
DECATUR MS
39327
US

IV. Provider business mailing address

P.O BOX 194
DECATUR MS
39327
US

V. Phone/Fax

Practice location:
  • Phone: 601-635-4131
  • Fax:
Mailing address:
  • Phone: 601-635-4131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT4343
License Number StateMS

VIII. Authorized Official

Name: MR. HAROLD D THOMPSON III
Title or Position: PHYSICAL THERAPIST
Credential: DPT
Phone: 601-616-3331