Provider Demographics
NPI:1790074631
Name:PARAGON REHAB, LLC
Entity Type:Organization
Organization Name:PARAGON REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-657-1000
Mailing Address - Street 1:323 INDUSTRIAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MS
Mailing Address - Zip Code:39645
Mailing Address - Country:US
Mailing Address - Phone:601-657-1000
Mailing Address - Fax:601-657-9121
Practice Address - Street 1:323 INDUSTRIAL PARK
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MS
Practice Address - Zip Code:39645-8069
Practice Address - Country:US
Practice Address - Phone:601-657-1000
Practice Address - Fax:601-657-9121
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLC OF LIBERTY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA 4044225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230121Medicaid
MS1912997685Medicare UPIN
MS255271Medicare PIN