Basic Information
| Provider Information | |||||||||
| NPI: | 1982008249 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACCELERATED REHABILITATION CENTER OF KENOSHA LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2998 MOMENTUM PL | ||||||||
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| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606895330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626570222 | ||||||||
| FaxNumber: | 2626577190 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 COMMERCE DR | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | GRAYSLAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600307807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475487782 | ||||||||
| FaxNumber: | 8475487784 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2014 | ||||||||
| LastUpdateDate: | 10/15/2014 | ||||||||
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| AuthorizedOfficialLastName: | WARNER | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8155772840 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 6726070002 | 01 | IL | DMERC | OTHER |