Provider Demographics
NPI:1689185597
Name:SOUTHERN PHYSICAL AND AQUATIC THERAPY, P.A.
Entity type:Organization
Organization Name:SOUTHERN PHYSICAL AND AQUATIC THERAPY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-509-0475
Mailing Address - Street 1:3161 HIGHWAY 334
Mailing Address - Street 2:
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863-6160
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:369 PEOPLES DRIVE
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863
Practice Address - Country:US
Practice Address - Phone:662-509-0475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy