Healthcare Provider Details

I. General information

NPI: 1568455889
Provider Name (Legal Business Name): PERFORMANCE REHAB, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 11/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 EAST COUNTYLINE ROAD SUITE A
RIDGELAND MS
39157
US

IV. Provider business mailing address

PO BOX 720610
BYRAM MS
39272-0610
US

V. Phone/Fax

Practice location:
  • Phone: 601-308-5117
  • Fax: 601-308-5103
Mailing address:
  • Phone: 601-308-5117
  • Fax: 601-308-5103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number0524742
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number0524742
License Number StateMS

VIII. Authorized Official

Name: MRS. SUZANNE S WALTERS
Title or Position: CEO
Credential: OTR L
Phone: 601-308-5117