Provider Demographics
NPI:1376659714
Name:KEWANEE PHYSICAL THERAPY AND REHAB SPECIALISTS LLC
Entity Type:Organization
Organization Name:KEWANEE PHYSICAL THERAPY AND REHAB SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIAND
Authorized Official - Suffix:
Authorized Official - Credentials:PT, ATC
Authorized Official - Phone:877-552-2996
Mailing Address - Street 1:PO BOX 3497
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-3497
Mailing Address - Country:US
Mailing Address - Phone:877-552-2996
Mailing Address - Fax:866-245-8064
Practice Address - Street 1:125 W SOUTH ST
Practice Address - Street 2:SUITE B
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-3715
Practice Address - Country:US
Practice Address - Phone:309-852-2200
Practice Address - Fax:309-852-2402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209860Medicare ID - Type Unspecified
IL5272470002Medicare NSC