Provider Demographics
NPI:1093715773
Name:EVANS REHABILITATION SERVICES, LLC
Entity Type:Organization
Organization Name:EVANS REHABILITATION SERVICES, LLC
Other - Org Name:LAKE OCONEE REHABILITATION AND PERFORMANCE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:A
Authorized Official - Last Name:LOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:706-868-1707
Mailing Address - Street 1:415 TOWN PARK BLVD.
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809
Mailing Address - Country:US
Mailing Address - Phone:706-868-1707
Mailing Address - Fax:706-868-1351
Practice Address - Street 1:415 TOWN PARK BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809
Practice Address - Country:US
Practice Address - Phone:706-868-1707
Practice Address - Fax:706-868-1351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6183120001Medicare NSC