Healthcare Provider Details

I. General information

NPI: 1528310604
Provider Name (Legal Business Name): MILESTONE REHABILITATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2012
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 GRANT AVENUE
PHILADELPHIA PA
19115-3160
US

IV. Provider business mailing address

1701 GRANT AVENUE
PHILADELPHIA PA
19115-3160
US

V. Phone/Fax

Practice location:
  • Phone: 215-856-7623
  • Fax: 215-969-2736
Mailing address:
  • Phone: 215-856-7623
  • Fax: 215-969-2736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number807427
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number807427
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. ELENA PLATONOVA
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 215-464-3838