=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699390385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELLARD PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2020
-----------------------------------------------------
Last Update Date | 06/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 290 SGT PRENTISS DR STE A
-----------------------------------------------------
City | NATCHEZ
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39120-4142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-600-2515
-----------------------------------------------------
Fax | 601-600-2515
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 290 SGT PRENTISS DR STE A
-----------------------------------------------------
City | NATCHEZ
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39120-4142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-600-2515
-----------------------------------------------------
Fax | 601-600-2515
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PT
-----------------------------------------------------
Name | ANDREW MICHAEL ELLARD
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 601-600-2515
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------