Basic Information
| Provider Information | |||||||||
| NPI: | 1578232377 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REHABTECH SUPPLY, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | LIFE TECH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 655 W GRAND AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601261061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888009445 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1826 CRAIG RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631464712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888009445 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2021 | ||||||||
| LastUpdateDate: | 03/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | DACY | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8888009445 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | REHABTECH SUPPLY, LLC | ||||||||
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| NPICertificationDate: | 03/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.