=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841861283
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REHAB SERVICE CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2021
-----------------------------------------------------
Last Update Date | 07/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4910 RAY RD STE 1
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-936-1861
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4910 RAY ROAD SUITE 1
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | JIM ROSSIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-253-6061
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------