Healthcare Provider Details

I. General information

NPI: 1942586383
Provider Name (Legal Business Name): SPORTS THERAPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2011
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 W JACKSON ST SUITE F
RIDGELAND MS
39157-2355
US

IV. Provider business mailing address

207 W JACKSON ST SUITE F
RIDGELAND MS
39157-2355
US

V. Phone/Fax

Practice location:
  • Phone: 601-898-9503
  • Fax: 601-898-4682
Mailing address:
  • Phone: 601-898-9503
  • Fax: 601-898-4682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: LEANNE PFISTER
Title or Position: ADMINISTRATOR
Credential:
Phone: 281-980-2997