Healthcare Provider Details

I. General information

NPI: 1851484422
Provider Name (Legal Business Name): DEREK WADE PUCKETT RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 03/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 HWY 49 SOUTH
FLORENCE MS
39073
US

IV. Provider business mailing address

3000 HWY 49 SOUTH
FLORENCE MS
39073
US

V. Phone/Fax

Practice location:
  • Phone: 601-845-8282
  • Fax: 601-845-8290
Mailing address:
  • Phone: 601-845-8282
  • Fax: 601-845-8290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT1702
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: