Basic Information
| Provider Information | |||||||||
| NPI: | 1174997514 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ENCORE REHABILITATION INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ENCORE REHAB ON 59 EVA ROAD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 251 JOHNSTON ST SE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356012515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563409708 | ||||||||
| FaxNumber: | 2563409624 | ||||||||
| Practice Location | |||||||||
| Address1: | 59 EVA RD | ||||||||
| Address2: | |||||||||
| City: | SOMERVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356706423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567730138 | ||||||||
| FaxNumber: | 2567730140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2015 | ||||||||
| LastUpdateDate: | 12/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HENDERSON | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2563501764 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | 12/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 529917620 | 05 | AL | MEDICAID | 1003819608 | 01 | AL | GROUP NPI | OTHER |