MEDICARE: KEWANEE PHYSICAL THERAPY AND REHAB SPECIALISTS

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	225100000X	Physical Therapist		IL

General Provider Information

NPI Number	:	1285740621
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEWANEE PHYSICAL THERAPY AND REHAB SPECIALISTS

Provider Business Mailing Address
First Line	:	PO BOX 3497
Second Line	:
City	:	STURTEVANT
State	:	WI
Zip	:	53177-0300
Country	:	US
Telephone Number	:	877-552-2996
Fax Number	:	262-898-8696

Provider Business Practice Location Address
First Line	:	101 S GALENA AVE
Second Line	:
City	:	WYOMING
State	:	IL
Zip	:	61491-1470
Country	:	US
Telephone Number	:	309-695-4010
Fax Number	:	309-852-2402

Authorized Official
Title or Position	:	CO-OWNER
Name	:	MR. JON DEBORD
Credential	:	PT, MS, ATC, SCS
Telephone Number	:	309-695-4010

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	08/22/2020

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