Healthcare Provider Details

I. General information

NPI: 1982018362
Provider Name (Legal Business Name): POWERBACK REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2014
Last Update Date: 02/21/2025
Certification Date: 02/21/2025
Deactivation Date: 04/18/2016
Reactivation Date: 06/01/2017

III. Provider practice location address

1022 E WESLEY DR
O FALLON IL
62269-6107
US

IV. Provider business mailing address

101 E STATE ST C/O BUSINESS DEVELOPMENT
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 618-607-5081
  • Fax:
Mailing address:
  • Phone: 800-728-8808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: IAN OPPEL
Title or Position: COO
Credential:
Phone: 980-254-7007