=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730388554
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GULF COAST REHABILITATION, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2007
-----------------------------------------------------
Last Update Date | 07/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1706 BIENVILLE BLVD
-----------------------------------------------------
City | OCEAN SPRINGS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39564-3073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-818-9164
-----------------------------------------------------
Fax | 228-818-9167
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 605
-----------------------------------------------------
City | OCEAN SPRINGS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39566-0605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-818-9164
-----------------------------------------------------
Fax | 228-818-9167
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MISS JOCELYN ALLEEN MAYFIELD
-----------------------------------------------------
Credential | MPT, OTR/L
-----------------------------------------------------
Telephone | 228-818-9164
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | PT3521
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------