Provider Demographics
NPI:1376786749
Name:SOVEREIGN REHABILITATION OF ILLINOIS LLC
Entity Type:Organization
Organization Name:SOVEREIGN REHABILITATION OF ILLINOIS LLC
Other - Org Name:SOVEREIGN REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:RAUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:773-755-7566
Mailing Address - Street 1:2835 N SHEFFIELD AVE
Mailing Address - Street 2:SUITE 401
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5081
Mailing Address - Country:US
Mailing Address - Phone:773-755-7566
Mailing Address - Fax:773-755-7580
Practice Address - Street 1:2835 N SHEFFIELD AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5081
Practice Address - Country:US
Practice Address - Phone:773-755-7566
Practice Address - Fax:773-755-7580
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOVEREIGN REHABILITATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-14
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070001827261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy