Individual
MR. CARROL SHANE FORTENBERRY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.T.
Contact information
Practice address
2844 TRACELAND AVE., TUPELO, MS 38801
(188) 863-9692
(662) 680-5097
Mailing address
2844 TRACELAND DR, TUPELO, MS 38801-4200
(188) 863-9692
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
PT0000008246
TN
225100000X
Physical Therapist
Primary
PT0345
MS
Other
Enumeration date
11/25/2009
Last updated
11/25/2009
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