Healthcare Provider Details

I. General information

NPI: 1144418138
Provider Name (Legal Business Name): CAIRO REHAB & FIT FORE GOLF INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N FRONT ST
MOUNDS IL
62964-1022
US

IV. Provider business mailing address

120 N FRONT ST
MOUNDS IL
62964-1022
US

V. Phone/Fax

Practice location:
  • Phone: 304-363-7000
  • Fax: 304-366-7413
Mailing address:
  • Phone: 304-363-7000
  • Fax: 304-366-7413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: GORDON D HOLDEN
Title or Position: OWNER
Credential: PT
Phone: 304-363-7000