Healthcare Provider Details

I. General information

NPI: 1619994431
Provider Name (Legal Business Name): BLOOMINGTON REHABILITATION ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 08/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 S MERCER AVE
BLOOMINGTON IL
61701-7107
US

IV. Provider business mailing address

1015 S MERCER AVE
BLOOMINGTON IL
61701-7107
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-7500
  • Fax: 309-662-7333
Mailing address:
  • Phone: 309-662-7500
  • Fax: 309-662-7333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID R JONES
Title or Position: CFO
Credential: CPA
Phone: 309-662-7500