Healthcare Provider Details

I. General information

NPI: 1194778183
Provider Name (Legal Business Name): PROREHAB, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3726 S KINGSHIGHWAY BLVD
SAINT LOUIS MO
63109-1800
US

IV. Provider business mailing address

600 OAKMONT LN STE 600C
WESTMONT IL
60559-5548
US

V. Phone/Fax

Practice location:
  • Phone: 314-351-7172
  • Fax: 314-351-6885
Mailing address:
  • Phone: 630-575-1980
  • Fax: 630-928-5080

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: JUANA L GRANADOS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 630-575-1980