Basic Information
| Provider Information | |||||||||
| NPI: | 1841629110 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMPREHAB, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2675 COURT DR | ||||||||
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| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280541478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048247800 | ||||||||
| FaxNumber: | 7048242853 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 CADDO CROSSING DR | ||||||||
| Address2: | |||||||||
| City: | GLENWOOD | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719438882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703564954 | ||||||||
| FaxNumber: | 8703564956 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2013 | ||||||||
| LastUpdateDate: | 03/08/2018 | ||||||||
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| AuthorizedOfficialLastName: | HORTON | ||||||||
| AuthorizedOfficialFirstName: | BEVERLY | ||||||||
| AuthorizedOfficialMiddleName: | BRUNSON | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9807450700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | EDS, MHQ | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 15614872 | 05 | AR | MEDICAID |