Healthcare Provider Details

I. General information

NPI: 1982799516
Provider Name (Legal Business Name): TRI-VISTA REHAB, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 CLARK BLVD A
TUPELO MS
38804-2801
US

IV. Provider business mailing address

PO BOX 3592
TUPELO MS
38803
US

V. Phone/Fax

Practice location:
  • Phone: 662-840-0535
  • Fax:
Mailing address:
  • Phone: 662-840-0535
  • Fax: 662-842-7915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MR. KEVIN TROY BOUTIN
Title or Position: PRESIDENT
Credential: OTR
Phone: 662-231-7304