=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811218423
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EFFINGHAM REHAB SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2010
-----------------------------------------------------
Last Update Date | 06/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4600 GOER DR STE 206
-----------------------------------------------------
City | NORTH CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29406-6500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-826-1509
-----------------------------------------------------
Fax | 912-826-9767
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 135 GOSHEN ROAD EXT STE 206
-----------------------------------------------------
City | RINCON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31326-5567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VPA
-----------------------------------------------------
Name | SEBRENA CAROLIN HOLMES GIBSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 877-826-1509
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------