Provider Demographics
NPI:1154445369
Name:JEFFERSON COUNTY REHABILITATION
Entity Type:Organization
Organization Name:JEFFERSON COUNTY REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:CIBULKA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:636-931-7600
Mailing Address - Street 1:1330 YMCA DR
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-2661
Mailing Address - Country:US
Mailing Address - Phone:636-931-7600
Mailing Address - Fax:636-931-8808
Practice Address - Street 1:1330 YMCA DR
Practice Address - Street 2:SUITE 1200
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-2661
Practice Address - Country:US
Practice Address - Phone:636-931-7600
Practice Address - Fax:636-931-8808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00947261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000014632Medicare PIN