=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134360555
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILKES REHAB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2009
-----------------------------------------------------
Last Update Date | 03/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1350 BAY SPRINGS CHURCH RD
-----------------------------------------------------
City | ADRIAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31002-4247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-668-3428
-----------------------------------------------------
Fax | 478-668-3428
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1350 BAY SPRINGS CHURCH RD
-----------------------------------------------------
City | ADRIAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31002-4247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-668-3428
-----------------------------------------------------
Fax | 478-668-3428
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGISTERED OCCUPATIONAL THERAPIST
-----------------------------------------------------
Name | MR. CHRISTOPHER WALLACE WILKES
-----------------------------------------------------
Credential | MSOT
-----------------------------------------------------
Telephone | 478-668-3428
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | OT004805
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------