Basic Information
| Provider Information | |||||||||
| NPI: | 1013186113 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REHABILITATIVE ASSOCIATES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MOHICAN SPORTS MEDICINE AND REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 812 COSHOCTON AVE | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430501947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403928811 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 17809 ROUTE 31 | ||||||||
| Address2: | MILL VALLEY PLAZA 9 | ||||||||
| City: | MARYSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403928811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2008 | ||||||||
| LastUpdateDate: | 12/29/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | TIELL | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7403928811 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.