Healthcare Provider Details

I. General information

NPI: 1063481711
Provider Name (Legal Business Name): ABBAMARK REHABILITATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18905 E 33RD STREET CT S
INDEPENDENCE MO
64057-3336
US

IV. Provider business mailing address

18905 E 33RD STREET CT S
INDEPENDENCE MO
64057-3336
US

V. Phone/Fax

Practice location:
  • Phone: 816-589-0100
  • Fax:
Mailing address:
  • Phone: 816-589-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. FREDERICK C. WILSON
Title or Position: PRESIDENT
Credential: PT ATC
Phone: 816-589-0100