Provider Demographics
NPI:1801984810
Name:COMMUNITY REHAB OF GREENVILLE INC
Entity type:Organization
Organization Name:COMMUNITY REHAB OF GREENVILLE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:FAYARD
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:228-436-0999
Mailing Address - Street 1:PO BOX 7066
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-7066
Mailing Address - Country:US
Mailing Address - Phone:228-436-0999
Mailing Address - Fax:228-436-0990
Practice Address - Street 1:3808 S LINDBERGH BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1367
Practice Address - Country:US
Practice Address - Phone:314-843-7800
Practice Address - Fax:314-843-7804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MONONE REQUIRED261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO186721OtherBCBS GROUP PROVIDER NUMBE
MO656018OtherHEALTHLINK GROUP PROVIDER
MO266638Medicare Oscar/Certification
MO186721OtherBCBS GROUP PROVIDER NUMBE