Provider Demographics
NPI:1013228790
Name:SOVEREIGN REHABILITATION OF ILLINOIS, LLC
Entity Type:Organization
Organization Name:SOVEREIGN REHABILITATION OF ILLINOIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:RAUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:773-755-7566
Mailing Address - Street 1:2835 N SHEFFIELD AVE SUITE 401
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5081
Mailing Address - Country:US
Mailing Address - Phone:773-755-7566
Mailing Address - Fax:
Practice Address - Street 1:390 E CONGRESS PKWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6202
Practice Address - Country:US
Practice Address - Phone:773-755-7566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-28
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy