Healthcare Provider Details

I. General information

NPI: 1205174638
Provider Name (Legal Business Name): SOUTHERN REHAB WORKS, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2013
Last Update Date: 01/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 HOOT OWL LN
WOLF LAKE IL
62998-1137
US

IV. Provider business mailing address

PO BOX 1652
MURPHYSBORO IL
62966-5152
US

V. Phone/Fax

Practice location:
  • Phone: 618-534-5670
  • Fax:
Mailing address:
  • Phone: 618-534-5670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number056.008780
License Number StateIL

VIII. Authorized Official

Name: MRS. STEPHANIE MARIE LAMPORT
Title or Position: OWNER
Credential: MOT,OTR/L
Phone: 618-534-5670