Provider Demographics
NPI:1780579045
Name:SOUTHERN PELVIC THERAPY LLC
Entity type:Organization
Organization Name:SOUTHERN PELVIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-891-9131
Mailing Address - Street 1:PO BOX 1266
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-1266
Mailing Address - Country:US
Mailing Address - Phone:229-502-9788
Mailing Address - Fax:229-217-4910
Practice Address - Street 1:250 DOC DARBYSHIRE RD STE 9
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31788-4168
Practice Address - Country:US
Practice Address - Phone:229-502-9788
Practice Address - Fax:229-217-4910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-09
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty