Organization
COMMUNITY REHAB OF GREENVILLE INC
Active
Other names
PIONEER SPORTS MEDICINE & PHYSICAL THERAPY
Organization subpart
No
Provider details
NPI number
Authorized official
MS. MELANIE L FAYARD P.T. (VICE PRESIDENT)
(228) 436-0999
Entity
Organization
Contact information
Practice address
3808 S LINDBERGH BLVD, SUITE 105, SAINT LOUIS, MO 63127-1367
(314) 843-7800
(314) 843-7804
Mailing address
PO BOX 7066, GULFPORT, MS 39506-7066
(228) 436-0999
(228) 436-0990
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
—
—
261QP2000X
Physical Therapy Clinic/Center
Primary
NONE REQUIRED
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
186721
BCBS GROUP PROVIDER NUMBE
MO
01
—
656018
HEALTHLINK GROUP PROVIDER
MO
Enumeration date
10/11/2006
Last updated
07/02/2008
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