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General NPI Number Information
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NPI Number | 1336367135
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Entity Type | Organization
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Legal Business Name | TRAIL BLAZIN THERAPY LLC
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Dates
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Enumeration Date | 04/24/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 260 BARNES RD
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City | FLORENCE
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State | MS
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Zip | 39073-8066
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Country | US
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Telephone | 601-845-0876
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Fax |
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Provider Business Mailing Address
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Address Line | 260 BARNES RD
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City | FLORENCE
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State | MS
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Zip | 39073-8066
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Country | US
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Telephone | 601-845-0876
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Fax |
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Authorized Official
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Title or Position | OWNER,MANAGER
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Name | MRS. RACHELLE BENTON
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Credential | P.T.
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Telephone | 601-845-0876
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | P.T.0978
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License Number State | MS
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