MEDICARE: TRI-VISTA REHAB, INC.

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	261QP2000X	Physical Therapy Clinic/Center	1011705	MS

General Provider Information

NPI Number	:	1942581277
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI-VISTA REHAB, INC.

Provider Business Mailing Address
First Line	:	PO BOX 3592
Second Line	:
City	:	TUPELO
State	:	MS
Zip	:	38803-3592
Country	:	US
Telephone Number	:	662-840-0535
Fax Number	:	662-842-7915

Provider Business Practice Location Address
First Line	:	3776 CROSSHAVEN DR
Second Line	:
City	:	VESTAVIA
State	:	AL
Zip	:	35223-2833
Country	:	US
Telephone Number	:	337-886-7097
Fax Number	:	866-522-1008

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. KEVIN TROY BOUTIN
Credential	:	OTR
Telephone Number	:	662-840-0535

Provider Enumeration Date	:	08/31/2011
Last Update Date	:	08/31/2011

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