Basic Information
| Provider Information | |||||||||
| NPI: | 1205174638 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN REHAB WORKS, LTD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1652 | ||||||||
| Address2: | |||||||||
| City: | MURPHYSBORO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629665152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185345670 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 580 HOOT OWL LN | ||||||||
| Address2: | |||||||||
| City: | WOLF LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629981137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185345670 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2013 | ||||||||
| LastUpdateDate: | 01/18/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAMPORT | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6185345670 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MOT,OTR/L | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | 056.008780 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.