MEDICARE: OVER THE MOUNTAIN REHAB, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PTH1468	AL

General Provider Information

NPI Number	:	1376610865
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OVER THE MOUNTAIN REHAB, INC

Provider Business Mailing Address
First Line	:	2204 LAKESHORE DR
Second Line	:	SUITE 150
City	:	HOMEWOOD
State	:	AL
Zip	:	35209-6729
Country	:	US
Telephone Number	:	205-423-9502
Fax Number	:	205-423-9504

Provider Business Practice Location Address
First Line	:	2204 LAKESHORE DR
Second Line	:	SUITE 150
City	:	HOMEWOOD
State	:	AL
Zip	:	35209-6729
Country	:	US
Telephone Number	:	205-423-9502
Fax Number	:	205-423-9504

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. LISA R BOR
Credential	:	PT
Telephone Number	:	205-423-9502

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	03/27/2009

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