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Organization
FITNESS CLINIC
Active
Organization
FITNESS CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. BARBARA MARIE BROADWATER (EXECUTIVE DIRECTOR)
(601) 983-7494
Entity
Organization
Contact information
Practice address
2219 GREENWAY DR, JACKSON, MS 39204-3202
(601) 983-7494
(601) 371-3993
Mailing address
2219 GREENWAY DR, JACKSON, MS 39204-3202
(601) 983-7494
(601) 371-3993
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
—
NULL
103TC0700X
Clinical Psychologist
—
—
225100000X
Physical Therapist
Primary
—
NULL
225100000X
Physical Therapist
Primary
—
—
Other
Enumeration date
02/02/2012
Last updated
02/02/2012
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