Provider Demographics
NPI:1316396815
Name:PEDIATRIC REHAB
Entity Type:Organization
Organization Name:PEDIATRIC REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LIBBY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BOBO
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:270-994-7751
Mailing Address - Street 1:5286 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-7466
Mailing Address - Country:US
Mailing Address - Phone:270-994-7751
Mailing Address - Fax:
Practice Address - Street 1:5286 PARKSIDE DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-7466
Practice Address - Country:US
Practice Address - Phone:270-994-7751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY200119099252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency