Basic Information
| Provider Information | |||||||||
| NPI: | 1407981475 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENCORE REHABILIATION INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ENCORE REHAB OF GULFPORT OG | ||||||||
| 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: | 15476B DEDEAUX RD | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395032637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2285393232 | ||||||||
| FaxNumber: | 2285393230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 12/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HENDERSON | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2563501764 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| 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 | 1033218524 | 01 | MS | GROUP NPI | OTHER | 090-15077 | 05 | MS | MEDICAID |