Provider Demographics
NPI:1265688188
Name:MAIN LINE REHABILITATION ASSOCIATES
Entity Type:Organization
Organization Name:MAIN LINE REHABILITATION ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-280-0180
Mailing Address - Street 1:668 EXTON CMNS
Mailing Address - Street 2:
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-2446
Mailing Address - Country:US
Mailing Address - Phone:610-280-0180
Mailing Address - Fax:610-280-0192
Practice Address - Street 1:668 EXTON CMNS
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-2446
Practice Address - Country:US
Practice Address - Phone:610-280-0180
Practice Address - Fax:610-280-0192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000009070001Medicaid