Healthcare Provider Details

I. General information

NPI: 1376659714
Provider Name (Legal Business Name): KEWANEE PHYSICAL THERAPY AND REHAB SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E 10TH ST
KEWANEE IL
61443-1330
US

IV. Provider business mailing address

PO BOX 3497
STURTEVANT WI
53177-3497
US

V. Phone/Fax

Practice location:
  • Phone: 309-852-2200
  • Fax: 309-852-2402
Mailing address:
  • Phone: 877-552-2996
  • Fax: 866-245-8064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070009875
License Number StateIL

VIII. Authorized Official

Name: JON A DEBORD
Title or Position: OWNER
Credential: PT, MS, ATC, SCS
Phone: 309-852-2200