Provider Demographics
NPI:1265977847
Name:MID SOUTH REHAB OUTPATIENT CLINIC LLC
Entity type:Organization
Organization Name:MID SOUTH REHAB OUTPATIENT CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF COMPLIANCE/HIM
Authorized Official - Prefix:
Authorized Official - First Name:CHARLEAN
Authorized Official - Middle Name:RANSOM
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L, CHC
Authorized Official - Phone:601-909-4210
Mailing Address - Street 1:599C STEED RD
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1707
Mailing Address - Country:US
Mailing Address - Phone:601-605-6777
Mailing Address - Fax:601-607-1415
Practice Address - Street 1:3131 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3418
Practice Address - Country:US
Practice Address - Phone:601-605-6777
Practice Address - Fax:601-607-1415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-05
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy