Healthcare Provider Details

I. General information

NPI: 1871973636
Provider Name (Legal Business Name): ELITE PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 06/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2319 HIGHWAY 145
SALTILLO MS
38866-9199
US

IV. Provider business mailing address

PO BOX 420
SALTILLO MS
38866-0420
US

V. Phone/Fax

Practice location:
  • Phone: 662-869-9980
  • Fax: 662-869-9970
Mailing address:
  • Phone: 662-869-9980
  • Fax: 662-869-9970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT3064
License Number StateMS

VIII. Authorized Official

Name: MRS. TINA MCCOLLUM
Title or Position: OFFICE MANAGER
Credential:
Phone: 662-869-9980