Basic Information
Provider Information | |||||||||
NPI: | 1720549892 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FIVE STAR REHABILITATION AND WELLNESS SERVICES, LLC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AGEILITY PHYSICAL THERAPY SOLUTIONS AT MEADOWOOD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 255 WASHINGTON ST STE 230 | ||||||||
Address2: |   | ||||||||
City: | NEWTON | ||||||||
State: | MA | ||||||||
PostalCode: | 024581644 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6177968387 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2455 N TAMARACK TRL | ||||||||
Address2: |   | ||||||||
City: | BLOOMINGTON | ||||||||
State: | IN | ||||||||
PostalCode: | 474081294 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8123367060 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2019 | ||||||||
LastUpdateDate: | 10/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEER | ||||||||
AuthorizedOfficialFirstName: | JEFFREY | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6177968387 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FIVE STAR REHABILITATION AND WELLNESS SERVICES, LLC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.