Provider Demographics
NPI:1235282880
Name:TRI-STATE REHABILITATION
Entity type:Organization
Organization Name:TRI-STATE REHABILITATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DELOACH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:229-253-8500
Mailing Address - Street 1:202 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2507
Mailing Address - Country:US
Mailing Address - Phone:229-253-8500
Mailing Address - Fax:229-253-8522
Practice Address - Street 1:202 W PARK AVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2507
Practice Address - Country:US
Practice Address - Phone:229-253-8500
Practice Address - Fax:229-253-8522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002693225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52592064 - 001OtherBLUE CROSS BLUE SHIELD
GA000802425AMedicaid
GA257139725OtherTRICARE