Provider Demographics
NPI:1114584612
Name:INJURY REHAB CENTER LLC
Entity Type:Organization
Organization Name:INJURY REHAB CENTER LLC
Other - Org Name:ADVANCED INJURY REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:WIETFELDT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:502-233-3456
Mailing Address - Street 1:102 MANOR AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-2553
Mailing Address - Country:US
Mailing Address - Phone:502-233-3456
Mailing Address - Fax:
Practice Address - Street 1:102 MANOR AVE STE 202
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-2553
Practice Address - Country:US
Practice Address - Phone:502-233-3456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-21
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty