Provider Demographics
NPI:1053533570
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:39507-7066
Mailing Address - Country:US
Mailing Address - Phone:228-436-0999
Mailing Address - Fax:228-436-0990
Practice Address - Street 1:3313 MARKET ST
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567
Practice Address - Country:US
Practice Address - Phone:228-762-1936
Practice Address - Fax:228-762-1926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS=========AOtherBCBS MS ID NUMBER