Provider Demographics
NPI:1144597139
Name:TRICARE REHAB
Entity Type:Organization
Organization Name:TRICARE REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROGDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-898-3422
Mailing Address - Street 1:12803 LENOVER ST.
Mailing Address - Street 2:
Mailing Address - City:DILLSBORO
Mailing Address - State:IN
Mailing Address - Zip Code:47018
Mailing Address - Country:US
Mailing Address - Phone:812-432-3610
Mailing Address - Fax:
Practice Address - Street 1:150 FENCL LN
Practice Address - Street 2:
Practice Address - City:HILLSIDE
Practice Address - State:IL
Practice Address - Zip Code:60162-2041
Practice Address - Country:US
Practice Address - Phone:812-432-3610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-19
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99048396A261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy