Provider Demographics
NPI:1578647780
Name:PHYSICAL THERAPY CENTER OF OCEAN SPRINGS, LLC
Entity type:Organization
Organization Name:PHYSICAL THERAPY CENTER OF OCEAN SPRINGS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:ROLL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:228-872-6821
Mailing Address - Street 1:PO BOX 834
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39566-0834
Mailing Address - Country:US
Mailing Address - Phone:228-872-6821
Mailing Address - Fax:228-872-6891
Practice Address - Street 1:900 HOLCOMB BLVD STE A
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564
Practice Address - Country:US
Practice Address - Phone:228-872-6821
Practice Address - Fax:228-872-6891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015691Medicaid
MS09015691Medicaid