Provider Demographics
NPI:1073842829
Name:COVENANT HEALTH & REHAB OF VICKSBURG, LLC
Entity Type:Organization
Organization Name:COVENANT HEALTH & REHAB OF VICKSBURG, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-937-7994
Mailing Address - Street 1:2850 PORTERS CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-1805
Mailing Address - Country:US
Mailing Address - Phone:601-638-9211
Mailing Address - Fax:601-636-4986
Practice Address - Street 1:2850 PORTERS CHAPEL RD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-1805
Practice Address - Country:US
Practice Address - Phone:601-638-9211
Practice Address - Fax:601-636-4986
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COVENANT DOVE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-08
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01787098Medicaid
255140Medicare Oscar/Certification