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General NPI Number Information
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NPI Number | 1528351798
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Entity Type | Organization
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Legal Business Name | ETHOS REHAB LLC
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Dates
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Enumeration Date | 05/22/2011
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Last Update Date | 05/22/2011
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Provider Practice Location Address
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Address Line | 100 SELBY DR
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City | MADISON
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State | MS
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Zip | 39110-9437
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Country | US
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Telephone | 601-946-8558
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Fax | 601-707-7408
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Provider Business Mailing Address
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Address Line | 100 SELBY DR
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City | MADISON
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State | MS
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Zip | 39110-9437
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Country | US
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Telephone | 601-946-8558
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Fax | 601-707-7408
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Authorized Official
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Title or Position | OWNER
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Name | CLAY J ECKERSON
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Credential | PT
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Telephone | 601-946-8558
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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 | PT2014
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License Number State | MS
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