Basic Information
| Provider Information | |||||||||
| NPI: | 1659457158 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEREK ENTERPRISES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRO REHABILITIATION SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1086 ROUTE 315 | ||||||||
| Address2: | |||||||||
| City: | PLAINS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708237761 | ||||||||
| FaxNumber: | 5708228033 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 ROTARY DRIVE | ||||||||
| Address2: | VALMONT INDUSTRIAL PARK | ||||||||
| City: | W HAZLETON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704596333 | ||||||||
| FaxNumber: | 5704595255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CASSETORI | ||||||||
| AuthorizedOfficialFirstName: | DON | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MGR TREAS | ||||||||
| AuthorizedOfficialTelephone: | 5708237761 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | X | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | X | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1507382 | 01 | PA | HIGHMARK BCBS | OTHER | 50042164 | 01 | PA | CAPITAL BCBS | OTHER | 315464 | 01 | PA | HEALTH AMERICA HLTH ASSUR | OTHER | 5234560 | 01 | PA | AETNA US HEALTHCARE | OTHER | 61915 | 01 | PA | GEISINGER | OTHER |