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General NPI Number Information
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NPI Number | 1831473453
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Entity Type | Organization
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Legal Business Name | TRIVISTA
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Dates
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Enumeration Date | 09/30/2011
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Last Update Date | 09/30/2011
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Provider Practice Location Address
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Address Line | 164 CR 512
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City | CORINTH
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State | MS
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Zip | 38834
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Country | US
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Telephone | 901-412-6441
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Fax |
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Provider Business Mailing Address
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Address Line | 164 COUNTY ROAD 512
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City | CORINTH
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State | MS
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Zip | 38834-8125
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Country | US
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Telephone | 901-412-6441
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Fax |
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Authorized Official
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Title or Position | OCCUPATIONAL THERAPIST
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Name | MS. MALLORY PARKS
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Credential | OTR/L
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Telephone | 901-412-6441
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | OT2627
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License Number State | MS
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