Provider Demographics
NPI:1093498610
Name:POWERBACK REHABILITATION LLC
Entity Type:Organization
Organization Name:POWERBACK REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:SHROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-896-0422
Mailing Address - Street 1:101 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-3109
Mailing Address - Country:US
Mailing Address - Phone:800-728-8808
Mailing Address - Fax:
Practice Address - Street 1:1515 KINGSRIDGE DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-4475
Practice Address - Country:US
Practice Address - Phone:405-676-7274
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation