Provider Demographics
NPI:1144577339
Name:TRI-VISTA REHAB, INC
Entity Type:Organization
Organization Name:TRI-VISTA REHAB, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:TROY
Authorized Official - Last Name:BOUTIN
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:662-840-0535
Mailing Address - Street 1:90A CLARK BLVD
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-2801
Mailing Address - Country:US
Mailing Address - Phone:662-840-0535
Mailing Address - Fax:662-842-7915
Practice Address - Street 1:90A CLARK BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-2801
Practice Address - Country:US
Practice Address - Phone:662-840-0535
Practice Address - Fax:662-842-7915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-07
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4554310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility