MEDICARE: PROREHAB, PC

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	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1194778183
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROREHAB, PC

Provider Business Mailing Address
First Line	:	600 OAKMONT LN STE 600C
Second Line	:
City	:	WESTMONT
State	:	IL
Zip	:	60559-5548
Country	:	US
Telephone Number	:	630-575-1980
Fax Number	:	630-928-5080

Provider Business Practice Location Address
First Line	:	3726 S KINGSHIGHWAY BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63109-1800
Country	:	US
Telephone Number	:	314-351-7172
Fax Number	:	314-351-6885

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	JUANA L GRANADOS
Credential	:
Telephone Number	:	630-575-1980

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	01/17/2020

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