MEDICARE: POWERBACK REHABILITATION 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	261QR0400X	Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1083079131
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POWERBACK REHABILITATION LLC

Provider Business Mailing Address
First Line	:	101 E STATE ST
Second Line	:	C/O AMY NUNEMAKER
City	:	KENNETT SQUARE
State	:	PA
Zip	:	19348-3109
Country	:	US
Telephone Number	:	610-925-4560
Fax Number	:

Provider Business Practice Location Address
First Line	:	12400 PRESTON RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75230-1866
Country	:	US
Telephone Number	:	469-899-0740
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	CARL ANTHONY SHROM
Credential	:
Telephone Number	:	215-896-0422

Provider Enumeration Date	:	12/16/2015
Last Update Date	:	02/27/2023

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