Healthcare Provider Details

I. General information

NPI: 1952614414
Provider Name (Legal Business Name): MEDICOMP PHYSICAL THERAPY RIDGELAND, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2010
Last Update Date: 07/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 S PEAR ORCHARD RD SUITE 114
RIDGELAND MS
39157-4861
US

IV. Provider business mailing address

665 S PEAR ORCHARD RD SUITE 114
RIDGELAND MS
39157-4861
US

V. Phone/Fax

Practice location:
  • Phone: 601-956-1211
  • Fax:
Mailing address:
  • Phone: 601-956-1211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. JOSEPH S MCNULTY III
Title or Position: CEO
Credential:
Phone: 601-849-1682