Healthcare Provider Details

I. General information

NPI: 1124687207
Provider Name (Legal Business Name): DONTAVIOUS TOLES PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 MAIN ST
WATER VALLEY MS
38965
US

IV. Provider business mailing address

104 COUNTY ROAD 550
WATER VALLEY MS
38965-3484
US

V. Phone/Fax

Practice location:
  • Phone: 662-473-4777
  • Fax:
Mailing address:
  • Phone: 662-801-2104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: