Healthcare Provider Details

I. General information

NPI: 1871862003
Provider Name (Legal Business Name): RECONNECT THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2011
Last Update Date: 12/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 W QUITMAN ST
IUKA MS
38852-1129
US

IV. Provider business mailing address

1410 W QUITMAN ST
IUKA MS
38852-1129
US

V. Phone/Fax

Practice location:
  • Phone: 662-423-3422
  • Fax: 662-423-5259
Mailing address:
  • Phone: 662-423-3422
  • Fax: 662-423-5259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number12072634
License Number StateMS

VIII. Authorized Official

Name: MRS. ELIZABETH KAVANAGH
Title or Position: PRESIDENT
Credential: PT
Phone: 251-605-4669