Provider Demographics
NPI:1982799516
Name:TRI-VISTA REHAB, INC
Entity Type:Organization
Organization Name:TRI-VISTA REHAB, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:TROY
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
Mailing Address - Country:US
Mailing Address - Phone:662-840-0535
Mailing Address - Fax:662-842-7915
Practice Address - Street 1:90 CLARK BLVD
Practice Address - Street 2:A
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-2801
Practice Address - Country:US
Practice Address - Phone:662-840-0535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS256596Medicare Oscar/Certification