Basic Information
| Provider Information | |||||||||
| NPI: | 1144624560 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDEPENDENCE REHABILITATION LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1425 PICKET DR | ||||||||
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| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176014583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178758909 | ||||||||
| FaxNumber: | 8186712225 | ||||||||
| Practice Location | |||||||||
| Address1: | 1237 W SHERMAN AVE | ||||||||
| Address2: | |||||||||
| City: | VINELAND | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083606920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178758909 | ||||||||
| FaxNumber: | 8186712225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2014 | ||||||||
| LastUpdateDate: | 10/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | XI | ||||||||
| AuthorizedOfficialFirstName: | FAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7178758909 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | MD431974 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.