Healthcare Provider Details

I. General information

NPI: 1578197703
Provider Name (Legal Business Name): GRADY MADISON KUYKENDALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 S MAIN ST
WATER VALLEY MS
38965-3468
US

IV. Provider business mailing address

711 AVIGNON DR
RIDGELAND MS
39157-5120
US

V. Phone/Fax

Practice location:
  • Phone: 662-473-5947
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT6816
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: