Provider Demographics
NPI:1093868788
Name:TRI-STATE REHABILITATION INC.
Entity Type:Organization
Organization Name:TRI-STATE REHABILITATION INC.
Other - Org Name:VALDOSTA PEDIATRIC THERAPY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:LARRY
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:229-253-8500
Mailing Address - Street 1:200 W MOORE ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2919
Mailing Address - Country:US
Mailing Address - Phone:229-253-8500
Mailing Address - Fax:229-253-8522
Practice Address - Street 1:200 W MOORE ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2919
Practice Address - Country:US
Practice Address - Phone:229-253-8500
Practice Address - Fax:229-253-8522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008640225100000X
GA000668225100000X
GA002693225100000X
GA000755225X00000X
GA003018225X00000X
GA003031225X00000X
GA002047235Z00000X
GA005367235Z00000X
GA004442235Z00000X
GA006513235Z00000X
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
GA300028433AMedicaid