Healthcare Provider Details

I. General information

NPI: 1659445286
Provider Name (Legal Business Name): PORTER COUNTY PHYSICAL MED REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 N ROOSEVELT ROAD STE 200 3
VALPARAISO IN
46383-0970
US

IV. Provider business mailing address

2600 N ROOSEVELT ROAD STE 200 3
VALPARAISO IN
46383-0970
US

V. Phone/Fax

Practice location:
  • Phone: 219-548-3828
  • Fax: 219-548-3803
Mailing address:
  • Phone: 219-548-3828
  • Fax: 219-548-3803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05003279A
License Number StateIN

VIII. Authorized Official

Name: MISS LISA M HAYES
Title or Position: INS COORDINATOR
Credential:
Phone: 219-548-3828