Provider Demographics
NPI:1386820165
Name:ADVANCED THERAPY& REHAB
Entity Type:Organization
Organization Name:ADVANCED THERAPY& REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL DIRECTOR OF THERAPY
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENIFER
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:DE LARA
Authorized Official - Suffix:
Authorized Official - Credentials:PT, CWS, GCS
Authorized Official - Phone:847-720-8851
Mailing Address - Street 1:6400 SHAFER CT
Mailing Address - Street 2:SUITE 600
Mailing Address - City:ROSEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60018-4914
Mailing Address - Country:US
Mailing Address - Phone:847-720-8700
Mailing Address - Fax:
Practice Address - Street 1:6400 SHAFER CT
Practice Address - Street 2:SUITE 600
Practice Address - City:ROSEMONT
Practice Address - State:IL
Practice Address - Zip Code:60018-4914
Practice Address - Country:US
Practice Address - Phone:847-720-8700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOULEVARD HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy