Healthcare Provider Details

I. General information

NPI: 1174042360
Provider Name (Legal Business Name): 2083 THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2017
Last Update Date: 04/24/2020
Certification Date: 04/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 CALDWELL DR
HAZLEHURST MS
39083-2723
US

IV. Provider business mailing address

100 PIONEER WAY
MAGEE MS
39111-5501
US

V. Phone/Fax

Practice location:
  • Phone: 601-894-9004
  • Fax:
Mailing address:
  • Phone: 601-849-6440
  • Fax: 601-849-1332

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: PRESIDENT
Credential:
Phone: 601-849-6440