Provider Demographics
NPI:1992941165
Name:CHR OF BOONEVILLE, INC.
Entity type:Organization
Organization Name:CHR OF BOONEVILLE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST / CLINIC OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:JEFF
Authorized Official - Last Name:STEPHENSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:662-720-7050
Mailing Address - Street 1:2405D E CHAMBERS DR
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-8927
Mailing Address - Country:US
Mailing Address - Phone:662-720-7050
Mailing Address - Fax:662-720-7055
Practice Address - Street 1:2405D E CHAMBERS DR
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-8927
Practice Address - Country:US
Practice Address - Phone:662-720-7050
Practice Address - Fax:662-720-7055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-18
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3039261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS009015370Medicaid