Provider Demographics
NPI:1356412803
Name:FIRST PLACE PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:FIRST PLACE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CARROLL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:PT OCS
Authorized Official - Phone:601-444-0030
Mailing Address - Street 1:433 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MS
Mailing Address - Zip Code:39429-3038
Mailing Address - Country:US
Mailing Address - Phone:601-444-0030
Mailing Address - Fax:601-444-0033
Practice Address - Street 1:433 BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-3038
Practice Address - Country:US
Practice Address - Phone:601-444-0030
Practice Address - Fax:601-444-0033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0549261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06231289Medicaid
MS=========OtherTAX ID NUMBER
MS06231289Medicaid