Healthcare Provider Details

I. General information

NPI: 1669381885
Provider Name (Legal Business Name): PHYSIOLETE THERAPY AND PERFORMANCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 COURTHOUSE CIR
FLOWOOD MS
39232-9521
US

IV. Provider business mailing address

PO BOX 2862
TUSCALOOSA AL
35403-2862
US

V. Phone/Fax

Practice location:
  • Phone: 769-208-3190
  • Fax: 769-208-3191
Mailing address:
  • Phone: 205-409-8060
  • Fax: 205-737-8841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: LAUREN C BUCKALEW
Title or Position: CO-OWNER
Credential: DPT
Phone: 769-208-3190