Healthcare Provider Details

I. General information

NPI: 1255860326
Provider Name (Legal Business Name): BRITTNEY GHOLAR DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 06/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 HIGHWAY 18 W
JACKSON MS
39209-9446
US

IV. Provider business mailing address

805 MADISON ST APT 202
JACKSON MS
39202-4153
US

V. Phone/Fax

Practice location:
  • Phone: 601-487-8456
  • Fax:
Mailing address:
  • Phone: 601-270-8638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT6196
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: