Provider Demographics
NPI:1427130798
Name:FULTON REHABILITATION SERVICES, PA
Entity type:Organization
Organization Name:FULTON REHABILITATION SERVICES, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:CRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:662-862-4104
Mailing Address - Street 1:PO BOX 455
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MS
Mailing Address - Zip Code:38843-0455
Mailing Address - Country:US
Mailing Address - Phone:662-862-4104
Mailing Address - Fax:662-862-4162
Practice Address - Street 1:1110 SOUTH ADAMS
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MS
Practice Address - Zip Code:38843-8443
Practice Address - Country:US
Practice Address - Phone:662-862-4101
Practice Address - Fax:662-862-4162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT1048261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00780270Medicaid
MS00780270Medicaid