Healthcare Provider Details

I. General information

NPI: 1972028520
Provider Name (Legal Business Name): FLINT CREEK PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2017
Last Update Date: 07/21/2022
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 FLORA GENE AVE W STE D
WIGGINS MS
39577-5008
US

IV. Provider business mailing address

321 FLORA GENE AVE W STE D
WIGGINS MS
39577-5008
US

V. Phone/Fax

Practice location:
  • Phone: 601-523-1994
  • Fax: 601-523-1995
Mailing address:
  • Phone: 601-528-1994
  • Fax: 601-528-1995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT4487
License Number StateMS

VIII. Authorized Official

Name: MR. RYAN H HARRELL
Title or Position: PHYSICAL THERAPIST/OWNER
Credential: DPT
Phone: 601-528-1994