Provider Demographics
NPI:1669538823
Name:OUTPATIENT REHABILITATION CENTER OF FULTON INC
Entity type:Organization
Organization Name:OUTPATIENT REHABILITATION CENTER OF FULTON INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:IZARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-862-3070
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MS
Mailing Address - Zip Code:38843-0188
Mailing Address - Country:US
Mailing Address - Phone:662-862-3070
Mailing Address - Fax:662-862-4970
Practice Address - Street 1:406 INTERCHANGE DRIVE
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MS
Practice Address - Zip Code:38843-8900
Practice Address - Country:US
Practice Address - Phone:662-862-3070
Practice Address - Fax:662-862-4970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS9015712Medicaid
MS9015712Medicaid