MEDICARE: SOUTHERN REHAB WORKS, LTD

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	056.008780	IL

General Provider Information

NPI Number	:	1205174638
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN REHAB WORKS, LTD

Provider Business Mailing Address
First Line	:	PO BOX 1652
Second Line	:
City	:	MURPHYSBORO
State	:	IL
Zip	:	62966-5152
Country	:	US
Telephone Number	:	618-534-5670
Fax Number	:

Provider Business Practice Location Address
First Line	:	580 HOOT OWL LN
Second Line	:
City	:	WOLF LAKE
State	:	IL
Zip	:	62998-1137
Country	:	US
Telephone Number	:	618-534-5670
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. STEPHANIE MARIE LAMPORT
Credential	:	MOT,OTR/L
Telephone Number	:	618-534-5670

Provider Enumeration Date	:	01/18/2013
Last Update Date	:	01/18/2013

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