=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811361785
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGILITAS USA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2015
-----------------------------------------------------
Last Update Date | 01/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3680 SANGANI BLVD STE D
-----------------------------------------------------
City | DIBERVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39540-8703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-273-0050
-----------------------------------------------------
Fax | 228-233-3443
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 CRESCENT CENTRE DR SUITE 600
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37067-7269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-656-0379
-----------------------------------------------------
Fax | 615-221-9054
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | ANDREW LANGE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-373-1350
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------