Basic Information
| Provider Information | |||||||||
| NPI: | 1962655852 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANGELIC REHABILITATION SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 742 | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457010742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402494081 | ||||||||
| FaxNumber: | 7402494126 | ||||||||
| Practice Location | |||||||||
| Address1: | 86 COLUMBUS CIRCLE | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457011331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402494081 | ||||||||
| FaxNumber: | 7402494126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2008 | ||||||||
| LastUpdateDate: | 01/06/2012 | ||||||||
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| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7402494081 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 008857 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2934918 | 05 | OH | MEDICAID |