Healthcare Provider Details

I. General information

NPI: 1235154048
Provider Name (Legal Business Name): GOLDEN TRIANGLE PHYSICAL THERAPY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/14/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17045 E MAIN ST
LOUISVILLE MS
39339-2754
US

IV. Provider business mailing address

17045 E MAIN ST
LOUISVILLE MS
39339-2754
US

V. Phone/Fax

Practice location:
  • Phone: 662-773-3700
  • Fax: 662-773-3727
Mailing address:
  • Phone: 662-773-3700
  • Fax: 662-773-3727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT1026
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MISTY DEMPSEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 662-773-3700