Basic Information
| Provider Information | |||||||||
| NPI: | 1598195067 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENCORE REHABILITATION INC | ||||||||
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| OtherOrganizationName: | ENCORE REHAB OF WEST POINT | ||||||||
| 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: | 1275 HIGHWAY 45 S | ||||||||
| Address2: | SUITE 1277 | ||||||||
| City: | WEST POINT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397739316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6624945579 | ||||||||
| FaxNumber: | 6624947612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2013 | ||||||||
| LastUpdateDate: | 11/20/2013 | ||||||||
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| AuthorizedOfficialLastName: | HENDERSON | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2563501764 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT5072 | MS | 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 |