Healthcare Provider Details

I. General information

NPI: 1972016848
Provider Name (Legal Business Name): 2083 THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 10/15/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5080 LAKELAND DR. SUITE B
FLOWOOD MS
39232-4403
US

IV. Provider business mailing address

100 PIONEER WAY
MAGEE MS
39111-5501
US

V. Phone/Fax

Practice location:
  • Phone: 769-572-5411
  • Fax: 769-572-5412
Mailing address:
  • Phone: 601-849-6440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JOSEPH S MCNULTY IV
Title or Position: CEO
Credential:
Phone: 601-849-6440