Provider Demographics
NPI:1346285673
Name:RESTORATION REHAB INC
Entity Type:Organization
Organization Name:RESTORATION REHAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:SHERON
Authorized Official - Last Name:BURT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:601-366-6171
Mailing Address - Street 1:6501 DOGWOOD VIEW PKWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-7857
Mailing Address - Country:US
Mailing Address - Phone:601-366-6171
Mailing Address - Fax:
Practice Address - Street 1:6501 DOGWOOD VIEW PKWY
Practice Address - Street 2:SUITE C
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-7857
Practice Address - Country:US
Practice Address - Phone:601-366-6171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT1297225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06229265Medicaid
MS64094670OtherEIN
MS06229265Medicaid
MSC03432Medicare ID - Type Unspecified