Healthcare Provider Details

I. General information

NPI: 1629081906
Provider Name (Legal Business Name): KEWANEE PHYSICAL THERAPY AND REHAB SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1258 W SOUTH ST SUITE 1
KEWANEE IL
61443-8300
US

IV. Provider business mailing address

PO BOX 3497
STURTEVANT WI
53177-3497
US

V. Phone/Fax

Practice location:
  • Phone: 866-932-5400
  • Fax: 309-932-8105
Mailing address:
  • Phone: 877-552-2996
  • Fax: 866-245-8064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070009875
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: LARRY D BRIAND
Title or Position: CO-OWNER
Credential:
Phone: 877-552-2996