=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598711970
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 92 BRICK ROAD OPERATING COMPANY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2006
-----------------------------------------------------
Last Update Date | 07/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 92 BRICK RD
-----------------------------------------------------
City | MARLTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08053-2177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-988-8778
-----------------------------------------------------
Fax | 856-988-6901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4550 LENA DR
-----------------------------------------------------
City | MECHANICSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17055-4922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-591-5709
-----------------------------------------------------
Fax | 717-591-5710
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MR. BRAD HOLLINGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 717-591-5700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 283X00000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Hospital
-----------------------------------------------------
License Number | 22252
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------