Provider Demographics
NPI:1386147817
Name:ACTIMED, LLC
Entity type:Organization
Organization Name:ACTIMED, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASPER
Authorized Official - Middle Name:WINTON
Authorized Official - Last Name:ADCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:PT, OT, RHIA
Authorized Official - Phone:601-722-2222
Mailing Address - Street 1:PO BOX 1577
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-1577
Mailing Address - Country:US
Mailing Address - Phone:601-722-2222
Mailing Address - Fax:601-722-4444
Practice Address - Street 1:1074 HIGHWAY 13 N
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-8568
Practice Address - Country:US
Practice Address - Phone:601-825-0101
Practice Address - Fax:601-825-0102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-12
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS5208225100000X
MS2255A2300X, 225700000X, 235Z00000X
MS2664225X00000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06529750Medicaid
MS3185373Medicaid
MS31853731Medicaid