Provider Demographics
NPI:1396459418
Name:III GEN
Entity type:Organization
Organization Name:III GEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:WILL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:III
Authorized Official - Credentials:DPT
Authorized Official - Phone:662-352-9386
Mailing Address - Street 1:PO BOX 1063
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39060-1063
Mailing Address - Country:US
Mailing Address - Phone:662-352-9386
Mailing Address - Fax:
Practice Address - Street 1:402 CYNTHIA ST STE E
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-3753
Practice Address - Country:US
Practice Address - Phone:601-460-1693
Practice Address - Fax:866-467-3612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
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
MS1114405263Medicaid