=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275112054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSAL REHABILITATION SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2021
-----------------------------------------------------
Last Update Date | 04/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6975 PROMWAY AVE NW
-----------------------------------------------------
City | NORTH CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44720-7321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-324-3109
-----------------------------------------------------
Fax | 330-305-6765
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6975 PROMWAY AVE NW
-----------------------------------------------------
City | NORTH CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44720-7321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-324-3109
-----------------------------------------------------
Fax | 330-305-6765
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LAURIE ANNE DENNIS
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 330-324-3109
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------