Healthcare Provider Details

I. General information

NPI: 1336522929
Provider Name (Legal Business Name): POWERBACK REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S MAPLEWOOD DR C/O EMERITUS AT MAPLEWOOD
BRIDGEPORT WV
26330-9593
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: 304-933-3338
  • Fax:
Mailing address:
  • Phone: 610-925-4560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

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