MEDICARE: REHAB LAB LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1053907196
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REHAB LAB LLC

Provider Business Mailing Address
First Line	:	2236 W CORNELIA AVE # 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-6035
Country	:	US
Telephone Number	:	224-456-7165
Fax Number	:

Provider Business Practice Location Address
First Line	:	2577 W ARMITAGE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-4324
Country	:	US
Telephone Number	:	224-456-7165
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHAEL RISHER
Credential	:	DC
Telephone Number	:	224-456-7165

Provider Enumeration Date	:	12/14/2020
Last Update Date	:	12/14/2020

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