Provider Demographics
NPI:1336127448
Name:PROGRESSIVE REHAB CARE, LLC
Entity Type:Organization
Organization Name:PROGRESSIVE REHAB CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:KHETARPAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-814-1555
Mailing Address - Street 1:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-0629
Mailing Address - Country:US
Mailing Address - Phone:910-814-1555
Mailing Address - Fax:
Practice Address - Street 1:1901 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-6824
Practice Address - Country:US
Practice Address - Phone:910-814-1555
Practice Address - Fax:910-814-1556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211831Medicaid
NC2346557Medicare ID - Type Unspecified