Organization
PERFORMANCE REHAB, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. SUZANNE S WALTERS OTR L (CEO)
(601) 308-5117
Entity
Organization
Contact information
Practice address
950 EAST COUNTYLINE ROAD, SUITE A, RIDGELAND, MS 39157
(601) 308-5117
(601) 308-5103
Mailing address
PO BOX 720610, BYRAM, MS 39272-0610
(601) 308-5117
(601) 308-5103
Taxonomy
Speciality
Code
Description
License number
State
261QP2000X
Physical Therapy Clinic/Center
Primary
0524742
MS
261QX0100X
Occupational Medicine Clinic/Center
0524742
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0007769666
AETNA PIN #
MS
05
—
09326565
—
MS
Enumeration date
08/23/2005
Last updated
11/16/2017
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