MEDICARE: OLD COLONY REHABILITATION LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1740060045
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLD COLONY REHABILITATION LLC

Provider Business Mailing Address
First Line	:	6161 HIGHWAY 547
Second Line	:
City	:	PORT GIBSON
State	:	MS
Zip	:	39150-2912
Country	:	US
Telephone Number	:	601-529-9084
Fax Number	:

Provider Business Practice Location Address
First Line	:	6161 HIGHWAY 547
Second Line	:
City	:	PORT GIBSON
State	:	MS
Zip	:	39150-2912
Country	:	US
Telephone Number	:	601-529-9084
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SUMMER FIFE
Credential	:	OT
Telephone Number	:	601-529-9084

Provider Enumeration Date	:	10/03/2023
Last Update Date	:	10/03/2023

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