Provider Demographics
NPI:1538969795
Name:PROACTIVE PHYSICAL THERAPY LLC.
Entity type:Organization
Organization Name:PROACTIVE PHYSICAL THERAPY LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENDRIQUE
Authorized Official - Middle Name:AKEEM
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:601-218-5004
Mailing Address - Street 1:701 ANTHONY ST
Mailing Address - Street 2:
Mailing Address - City:PORT GIBSON
Mailing Address - State:MS
Mailing Address - Zip Code:39150-2053
Mailing Address - Country:US
Mailing Address - Phone:601-218-5004
Mailing Address - Fax:
Practice Address - Street 1:701 ANTHONY ST
Practice Address - Street 2:
Practice Address - City:PORT GIBSON
Practice Address - State:MS
Practice Address - Zip Code:39150-2053
Practice Address - Country:US
Practice Address - Phone:601-218-5004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty