Basic Information
| Provider Information | |||||||||
| NPI: | 1053837112 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOPE LIFE AND REHABILITATION CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 MAIN ST UNIT G | ||||||||
| Address2: | |||||||||
| City: | HILTON HEAD ISLAND | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299266603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437154146 | ||||||||
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| Practice Location | |||||||||
| Address1: | 60 MAIN ST UNIT G | ||||||||
| Address2: | |||||||||
| City: | HILTON HEAD ISLAND | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299266603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437154146 | ||||||||
| FaxNumber: | 8437154673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2017 | ||||||||
| LastUpdateDate: | 01/31/2018 | ||||||||
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| AuthorizedOfficialLastName: | ITTENBACH | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | RICHARD | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MBR | ||||||||
| AuthorizedOfficialTelephone: | 8437154146 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4852 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1548360472 | 05 | SC | MEDICAID |