Healthcare Provider Details

I. General information

NPI: 1881071926
Provider Name (Legal Business Name): POWERBACK REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5025 ANN ARBOR RD C/O LEGACY ASSISTED LIVING
JACKSON MI
49201-8801
US

IV. Provider business mailing address

101 E STATE ST C/O AMY NUNEMAKER
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 517-879-1505
  • Fax:
Mailing address:
  • Phone: 610-925-4560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: CARL ANTHONY SHROM
Title or Position: CEO
Credential:
Phone: 215-896-0422