Basic Information
| Provider Information | |||||||||
| NPI: | 1467549857 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LICKING REHABILITATION SERVICES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | REHAB ASSOCIATES - NEWARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1117 LAMBS LN | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407630408 | ||||||||
| FaxNumber: | 7407630475 | ||||||||
| Practice Location | |||||||||
| Address1: | 159 WEST MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430555007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407630408 | ||||||||
| FaxNumber: | 7407630475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 05/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | KONKLER | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7407600408 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 2469510 | 05 | OH | MEDICAID |