Provider Demographics
NPI:1053523209
Name:PREMIER PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:PREMIER PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:601-888-7944
Mailing Address - Street 1:558 1ST SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:WOODVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39669-3777
Mailing Address - Country:US
Mailing Address - Phone:601-888-7944
Mailing Address - Fax:601-888-7687
Practice Address - Street 1:558 1ST SOUTH ST
Practice Address - Street 2:
Practice Address - City:WOODVILLE
Practice Address - State:MS
Practice Address - Zip Code:39669-3777
Practice Address - Country:US
Practice Address - Phone:601-888-7944
Practice Address - Fax:601-888-7687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016186Medicaid