=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629136437
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERRY COUNTY REHAB & DIAGNOSTIC CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 DR MIKE CLOUSE DRIVE
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-743-3800
-----------------------------------------------------
Fax | 740-743-3900
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2405 N COLUMBUS ST SUITE 140
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43130-8185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-743-3800
-----------------------------------------------------
Fax | 740-743-3900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. ANTHONY EDWARD KORDACK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 740-687-0036
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------