Basic Information
Provider Information | |||||||||
NPI: | 1104909217 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | REHABILITATIVE ASSOCIATES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MOHICAN SPORT MEDICINE AND REHAB | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 112 HARCOURT RD | ||||||||
Address2: | SUITE 1 | ||||||||
City: | MOUNT VERNON | ||||||||
State: | OH | ||||||||
PostalCode: | 430503946 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403928811 | ||||||||
FaxNumber: | 7403926485 | ||||||||
Practice Location | |||||||||
Address1: | 351 S LANE ST | ||||||||
Address2: | SUITE 1 | ||||||||
City: | BUCYRUS | ||||||||
State: | OH | ||||||||
PostalCode: | 448202319 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4195626686 | ||||||||
FaxNumber: | 4195626625 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/23/2006 | ||||||||
LastUpdateDate: | 09/11/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TIELL | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
AuthorizedOfficialTelephone: | 7403928811 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 225100000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.