Basic Information
| Provider Information | |||||||||
| NPI: | 1902137409 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REHABTECH SUPPLY, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LIFE TECH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 655 W GRAND AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601261060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888009445 | ||||||||
| FaxNumber: | 8888001991 | ||||||||
| Practice Location | |||||||||
| Address1: | 655 W GRAND AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ELMHURST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601261060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888009445 | ||||||||
| FaxNumber: | 8888001991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2010 | ||||||||
| LastUpdateDate: | 03/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DACY | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8888009445 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 69000699A | IN | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332B00000X | 203001157 | IL | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 200994870 A | 05 | IN | MEDICAID | 620078942 | 05 | MO | MEDICAID | 1902137409 | 05 | WI | MEDICAID |