Basic Information
Provider Information | |||||||||
NPI: | 1750869905 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ENCORE REHABILITATION INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ENCORE REHAB OF FORT PAYNE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 251 JOHNSTON ST SE STE 200 | ||||||||
Address2: |   | ||||||||
City: | DECATUR | ||||||||
State: | AL | ||||||||
PostalCode: | 356012515 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 1256350176 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 200 MEDICAL CENTER DR SW | ||||||||
Address2: |   | ||||||||
City: | FORT PAYNE | ||||||||
State: | AL | ||||||||
PostalCode: | 359683458 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2569972460 | ||||||||
FaxNumber: | 2569972815 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2018 | ||||||||
LastUpdateDate: | 12/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HENDERSON | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2563501764 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ENCORE REHABILIATION INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   |
No ID Information.