Basic Information
| Provider Information | |||||||||
| NPI: | 1356598478 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REHAB ENGINEERING LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1719 MAHAN DR | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323085201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506563599 | ||||||||
| FaxNumber: | 8506566483 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 N DAWSON ST | ||||||||
| Address2: | |||||||||
| City: | THOMASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317925132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778156557 | ||||||||
| FaxNumber: | 8506566483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2008 | ||||||||
| LastUpdateDate: | 06/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | FREDRICK | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | RYAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8506563599 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | 14 | GA | Y | Suppliers | Prosthetic/Orthotic Supplier |
ID Information
| ID | Type | State | Issuer | Description | 746347392A | 05 | GA | MEDICAID |