Healthcare Provider Details

I. General information

NPI: 1811109457
Provider Name (Legal Business Name): BELHAVEN PHYSICAL THERAPY CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1054 GREYMONT AVE
JACKSON MS
39202-2718
US

IV. Provider business mailing address

1054 GREYMONT AVE
JACKSON MS
39202-2718
US

V. Phone/Fax

Practice location:
  • Phone: 601-355-9624
  • Fax: 601-353-6151
Mailing address:
  • Phone: 601-355-9624
  • Fax: 601-353-6151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT2289
License Number StateMS

VIII. Authorized Official

Name: MARK BELCHER
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 601-355-9624