Basic Information
| Provider Information | |||||||||
| NPI: | 1003233271 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ENCORE REHABILITATION INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ENCORE REHAB OF GRENADA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8419 | ||||||||
| Address2: | |||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395358087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2283885714 | ||||||||
| FaxNumber: | 2283880017 | ||||||||
| Practice Location | |||||||||
| Address1: | 1322C SUNSET DR | ||||||||
| Address2: | |||||||||
| City: | GRENADA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389014000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2283885714 | ||||||||
| FaxNumber: | 2283880017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2014 | ||||||||
| LastUpdateDate: | 12/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | USELTON | ||||||||
| AuthorizedOfficialFirstName: | LEIGH | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 2283885714 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 09015077 | 05 | MS | MEDICAID |