MEDICARE: PROFESSIONAL REHAB

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	225100000X	Physical Therapist	4344	TN

General Provider Information

NPI Number	:	1801906045
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL REHAB

Provider Business Mailing Address
First Line	:	6231 RAVENWOOD CV
Second Line	:
City	:	HORN LAKE
State	:	MS
Zip	:	38637-2588
Country	:	US
Telephone Number	:	901-438-8799
Fax Number	:	662-280-3324

Provider Business Practice Location Address
First Line	:	6231 RAVENWOOD CV
Second Line	:
City	:	HORN LAKE
State	:	MS
Zip	:	38637-2588
Country	:	US
Telephone Number	:	901-438-8799
Fax Number	:	662-280-3324

Authorized Official
Title or Position	:	PHYSICAL THERAPIST/PRESIDENT
Name	:	JACQUELINE RUEDA
Credential	:	PT.
Telephone Number	:	901-438-8799

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	08/22/2020

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