Basic Information
Provider Information | |||||||||
NPI: | 1174867253 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ENCORE REHABILITATION INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ENCORE REHAB OF STARKVILLE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 8419 | ||||||||
Address2: |   | ||||||||
City: | BILOXI | ||||||||
State: | MS | ||||||||
PostalCode: | 395358087 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2283885714 | ||||||||
FaxNumber: | 2283880017 | ||||||||
Practice Location | |||||||||
Address1: | 450 HIGHWAY 12 W | ||||||||
Address2: | SUITE D | ||||||||
City: | STARKVILLE | ||||||||
State: | MS | ||||||||
PostalCode: | 397593697 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6623241314 | ||||||||
FaxNumber: | 6623241317 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/15/2012 | ||||||||
LastUpdateDate: | 11/30/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HENDERSON | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2563501764 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 | 1033218524 | 01 | MS | GROUP NPI | OTHER | 09015077 | 05 | MS |   | MEDICAID |