=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376659714
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEWANEE PHYSICAL THERAPY AND REHAB SPECIALISTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2006
-----------------------------------------------------
Last Update Date | 11/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 E 10TH ST
-----------------------------------------------------
City | KEWANEE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61443-1330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-852-2200
-----------------------------------------------------
Fax | 309-852-2402
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3497
-----------------------------------------------------
City | STURTEVANT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53177-3497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-552-2996
-----------------------------------------------------
Fax | 866-245-8064
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JON A DEBORD
-----------------------------------------------------
Credential | PT, MS, ATC, SCS
-----------------------------------------------------
Telephone | 309-852-2200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 070009875
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------