=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942581277
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRI-VISTA REHAB, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2011
-----------------------------------------------------
Last Update Date | 08/31/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3776 CROSSHAVEN DR
-----------------------------------------------------
City | VESTAVIA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35223-2833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-886-7097
-----------------------------------------------------
Fax | 866-522-1008
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3592
-----------------------------------------------------
City | TUPELO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38803-3592
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-840-0535
-----------------------------------------------------
Fax | 662-842-7915
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. KEVIN TROY BOUTIN
-----------------------------------------------------
Credential | OTR
-----------------------------------------------------
Telephone | 662-840-0535
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 1011705
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------