Healthcare Provider Details

I. General information

NPI: 1285740621
Provider Name (Legal Business Name): KEWANEE PHYSICAL THERAPY AND REHAB SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S GALENA AVE
WYOMING IL
61491-1470
US

IV. Provider business mailing address

PO BOX 3497
STURTEVANT WI
53177-0300
US

V. Phone/Fax

Practice location:
  • Phone: 309-695-4010
  • Fax: 309-852-2402
Mailing address:
  • Phone: 877-552-2996
  • Fax: 262-898-8696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. JON DEBORD
Title or Position: CO-OWNER
Credential: PT, MS, ATC, SCS
Phone: 309-695-4010