Healthcare Provider Details

I. General information

NPI: 1104032465
Provider Name (Legal Business Name): REHAB, ETC., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 09/01/2021
Certification Date: 09/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

871 RIDGEWAY LOOP RD STE 100
MEMPHIS TN
38120-4026
US

IV. Provider business mailing address

871 RIDGEWAY LOOP RD STE 100
MEMPHIS TN
38120-4026
US

V. Phone/Fax

Practice location:
  • Phone: 901-759-1282
  • Fax: 901-759-1290
Mailing address:
  • Phone: 901-759-1282
  • Fax: 901-759-1290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number204667
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number204667
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number204667
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number204667
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number204667
License Number StateTN
# 6
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number204667
License Number StateTN
# 7
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number0446575
License Number StateTN

VIII. Authorized Official

Name: MRS. PHYLLIS KNOSE
Title or Position: VICE PRESIDANT
Credential:
Phone: 901-759-1282