Healthcare Provider Details

I. General information

NPI: 1134135833
Provider Name (Legal Business Name): GENESIS PHYSICAL THERAPY & REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 E LAYFAIR DR SUITE B
FLOWOOD MS
39232-9526
US

IV. Provider business mailing address

290 E LAYFAIR DR SUITE B
FLOWOOD MS
39232-9526
US

V. Phone/Fax

Practice location:
  • Phone: 601-983-1200
  • Fax: 601-983-1205
Mailing address:
  • Phone: 601-983-1200
  • Fax: 601-983-1205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. CLARENCE WAYNE WHITLEY
Title or Position: C.O.O.
Credential:
Phone: 601-898-7527