Provider Demographics
NPI:1205061173
Name:SHILOH RIDGE ATHLETIC CLUB
Entity type:Organization
Organization Name:SHILOH RIDGE ATHLETIC CLUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-287-5662
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:662-287-5662
Mailing Address - Fax:662-287-5662
Practice Address - Street 1:3303 SHILOH RIDGE RD
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9698
Practice Address - Country:US
Practice Address - Phone:662-287-5662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI-VISTA REHAB INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-21
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS256596Medicare PIN