Healthcare Provider Details

I. General information

NPI: 1164527628
Provider Name (Legal Business Name): FOUR SEASONS REHAB, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 08/22/2020
Certification Date: 04/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 1/2 SPRUCE ST
BLUEFIELD VA
24605-1738
US

IV. Provider business mailing address

PO BOX 536
BLUEFIELD VA
24605-0536
US

V. Phone/Fax

Practice location:
  • Phone: 276-322-5511
  • Fax: 276-322-2525
Mailing address:
  • Phone: 276-322-5511
  • Fax: 276-322-2525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number2202001125
License Number StateVA

VIII. Authorized Official

Name: MRS. VICTORIA BOURNE
Title or Position: PRESIDENT
Credential: M.S., CCC-SLP
Phone: 276-322-5511