Provider Demographics
NPI:1730388554
Name:GULF COAST REHABILITATION, PC
Entity type:Organization
Organization Name:GULF COAST REHABILITATION, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:JOCELYN
Authorized Official - Middle Name:ALLEEN
Authorized Official - Last Name:MAYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, OTR/L
Authorized Official - Phone:228-818-9164
Mailing Address - Street 1:PO BOX 605
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39566-0605
Mailing Address - Country:US
Mailing Address - Phone:228-818-9164
Mailing Address - Fax:228-818-9167
Practice Address - Street 1:1706 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3073
Practice Address - Country:US
Practice Address - Phone:228-818-9164
Practice Address - Fax:228-818-9167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3521261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08635794Medicaid
MS08635794Medicaid