Provider Demographics
NPI:1134540222
Name:TRI-VISTA REHAB, INC.
Entity type:Organization
Organization Name:TRI-VISTA REHAB, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTIN
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:662-231-7304
Mailing Address - Street 1:PO BOX 3592
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-3592
Mailing Address - Country:US
Mailing Address - Phone:662-840-0535
Mailing Address - Fax:662-842-7915
Practice Address - Street 1:2160 HIGHLAND AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-4002
Practice Address - Country:US
Practice Address - Phone:662-231-7304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-17
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty