Healthcare Provider Details

I. General information

NPI: 1679683627
Provider Name (Legal Business Name): JOHN H KIRK III PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 03/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

394 COURTHOUSE RD SUITE B
GULFPORT MS
39507-1865
US

IV. Provider business mailing address

PO BOX 8419
BILOXI MS
39535-8087
US

V. Phone/Fax

Practice location:
  • Phone: 228-896-1189
  • Fax: 228-896-9989
Mailing address:
  • Phone: 228-388-5714
  • Fax: 228-388-0017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT3606
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: