Provider Demographics
NPI:1184188443
Name:AGE REHAB & MEDICAL FITNESS
Entity Type:Organization
Organization Name:AGE REHAB & MEDICAL FITNESS
Other - Org Name:AGE REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:ERUDE
Authorized Official - Last Name:LIDAYWA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:309-833-1004
Mailing Address - Street 1:1701 W JACKSON ST STE C
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3175
Mailing Address - Country:US
Mailing Address - Phone:309-331-3590
Mailing Address - Fax:
Practice Address - Street 1:1701 W JACKSON ST STE C
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3175
Practice Address - Country:US
Practice Address - Phone:309-331-3590
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-30
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy