Basic Information
| Provider Information | |||||||||
| NPI: | 1427200971 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ENCORE REHABILITATION, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ENCORE REHAB OF BAYOU LA BATRE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1908 FLINT RD SE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356016031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563501764 | ||||||||
| FaxNumber: | 2563507757 | ||||||||
| Practice Location | |||||||||
| Address1: | 13040 N WINTZELL AVE | ||||||||
| Address2: | OFFICE # 2 | ||||||||
| City: | BAYOU LA BATRE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365092110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2518242882 | ||||||||
| FaxNumber: | 2518242884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2008 | ||||||||
| LastUpdateDate: | 05/12/2010 | ||||||||
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| AuthorizedOfficialLastName: | HENDERSON | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2563501764 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | AL | 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 |