Provider Demographics
NPI:1376960310
Name:MOUNTAIN REHABILITATION SERVICES, LLC.
Entity Type:Organization
Organization Name:MOUNTAIN REHABILITATION SERVICES, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:MAGUET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-524-4287
Mailing Address - Street 1:702 PHILLIPS LN
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-2144
Mailing Address - Country:US
Mailing Address - Phone:606-524-4287
Mailing Address - Fax:606-862-8517
Practice Address - Street 1:606 KNOX ST
Practice Address - Street 2:
Practice Address - City:BARBOURVILLE
Practice Address - State:KY
Practice Address - Zip Code:40906-1304
Practice Address - Country:US
Practice Address - Phone:606-627-9905
Practice Address - Fax:606-277-0027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-27
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY002081225100000X
KY005497225100000X
KYA01560225200000X
KYA02336225200000X
KY134657225X00000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100458630Medicaid
KY7100464380Medicaid
KY87020814Medicaid