Basic Information
| Provider Information | |||||||||
| NPI: | 1417502246 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROREHAB PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 OAKMONT LN STE 600C | ||||||||
| Address2: | |||||||||
| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605595548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305756250 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2900 TRIMBLE RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652017180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733977036 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2019 | ||||||||
| LastUpdateDate: | 08/08/2019 | ||||||||
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| AuthorizedOfficialLastName: | GRANADOS | ||||||||
| AuthorizedOfficialFirstName: | JUANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6305751980 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROREHAB PC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.