Basic Information
Provider Information | |||||||||
NPI: | 1609259563 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ACCELERATED REHABILITATION CENTER OF KENOSHA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2998 MOMENTUM PL | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606895330 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2626570222 | ||||||||
FaxNumber: | 2626577190 | ||||||||
Practice Location | |||||||||
Address1: | 1186 W MAPLE AVE | ||||||||
Address2: |   | ||||||||
City: | MUNDELEIN | ||||||||
State: | IL | ||||||||
PostalCode: | 600601438 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8479707099 | ||||||||
FaxNumber: | 8479707719 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2015 | ||||||||
LastUpdateDate: | 08/28/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EXNER | ||||||||
AuthorizedOfficialFirstName: | TASYA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | UPFRONT SYSTEMS DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2626570222 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.