Healthcare Provider Details

I. General information

NPI: 1053825943
Provider Name (Legal Business Name): EXOS PHYSICAL THERAPY & SPORTS MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6542 GOODMAN RD STE 101
OLIVE BRANCH MS
38654-5559
US

IV. Provider business mailing address

50 BAY ST
CLANTON AL
35045-3000
US

V. Phone/Fax

Practice location:
  • Phone: 205-259-3991
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: GREG PERRY
Title or Position: PRESIDENT
Credential:
Phone: 205-259-3991