Healthcare Provider Details

I. General information

NPI: 1760420327
Provider Name (Legal Business Name): DIVERSIFIED REHAB SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

429 S BLANCHE ST SUITE 210
MOUNDS IL
62964-1107
US

IV. Provider business mailing address

101 PARK CIR
BENTON IL
62812-3464
US

V. Phone/Fax

Practice location:
  • Phone: 618-745-9419
  • Fax: 618-745-9421
Mailing address:
  • Phone: 618-534-9678
  • Fax: 618-435-2346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BENJAMIN N RICE
Title or Position: OWNER
Credential:
Phone: 618-534-9678