Basic Information
Provider Information | |||||||||
NPI: | 1467692426 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KEYSTONE REHABILITATION SYSTEMS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KEYSTONE REHABILITATION SYSTEMS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 665 PHILADELPHIA ST | ||||||||
Address2: |   | ||||||||
City: | INDIANA | ||||||||
State: | PA | ||||||||
PostalCode: | 157013941 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7244653496 | ||||||||
FaxNumber: | 2154134682 | ||||||||
Practice Location | |||||||||
Address1: | 2627 COLUMBIA BLVD | ||||||||
Address2: | BLOOMSBURG SPORTS PLEX | ||||||||
City: | BLOOMSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 178158831 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5703874815 | ||||||||
FaxNumber: | 5703874852 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/03/2009 | ||||||||
LastUpdateDate: | 06/15/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POOL | ||||||||
AuthorizedOfficialFirstName: | JAYNE | ||||||||
AuthorizedOfficialMiddleName: | FLECK | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 4694678705 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.