Provider Demographics
NPI:1831132562
Name:ADVANCED MEDICAL REHABILITATION, LLC
Entity Type:Organization
Organization Name:ADVANCED MEDICAL REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-624-2466
Mailing Address - Street 1:1051 LEE DRIVE
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-3616
Mailing Address - Country:US
Mailing Address - Phone:662-624-2466
Mailing Address - Fax:662-624-4876
Practice Address - Street 1:1051 LEE DR
Practice Address - Street 2:SUITE 1B
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-3615
Practice Address - Country:US
Practice Address - Phone:662-624-2466
Practice Address - Fax:662-624-4876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR659975363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC03363Medicare ID - Type UnspecifiedGROUP NUMBER