Provider Demographics
NPI:1093114498
Name:SOVEREIGN REHAB
Entity Type:Organization
Organization Name:SOVEREIGN REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:RAUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:630-585-7337
Mailing Address - Street 1:1315 MACOM DR STE 103
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-9360
Mailing Address - Country:US
Mailing Address - Phone:630-585-7337
Mailing Address - Fax:
Practice Address - Street 1:1315 MACOM DR. SUITE 103
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564
Practice Address - Country:US
Practice Address - Phone:630-585-7337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070001782261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center