Healthcare Provider Details

I. General information

NPI: 1306962899
Provider Name (Legal Business Name): ORTHOPEDIC REHABILITATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 HIGHWAY 15 N SUITE A
LAUREL MS
39440-1838
US

IV. Provider business mailing address

2015 HIGHWAY 15 N SUITE A
LAUREL MS
39440-1838
US

V. Phone/Fax

Practice location:
  • Phone: 601-425-2363
  • Fax: 601-425-3201
Mailing address:
  • Phone: 601-425-2363
  • Fax: 601-425-3201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RANDY BICKER
Title or Position: ADMINISTRATOR
Credential:
Phone: 601-425-2363