Provider Demographics
NPI:1215204862
Name:CUSTOM REHAB LLC
Entity Type:Organization
Organization Name:CUSTOM REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCKEE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-244-1882
Mailing Address - Street 1:857 SHEBA RD
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2522
Mailing Address - Country:US
Mailing Address - Phone:208-244-1882
Mailing Address - Fax:
Practice Address - Street 1:265 E CHUBBUCK RD
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-5055
Practice Address - Country:US
Practice Address - Phone:208-244-1882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-28
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty