=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780908475
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REHAB IN MOTION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2010
-----------------------------------------------------
Last Update Date | 12/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 LAKE RIDGE DR
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39110-8291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-898-8111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 LAKE RIDGE DR
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39110-8291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-898-8111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DARON WALTERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-573-9712
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------