Provider Demographics
NPI:1407523657
Name:REHAB SPECIALISTS OUTPATIENT LLC
Entity Type:Organization
Organization Name:REHAB SPECIALISTS OUTPATIENT LLC
Other - Org Name:AGESTRONG MIRABELLA ASU
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:G
Authorized Official - Last Name:FOGG
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:971-206-5200
Mailing Address - Street 1:4560 SE INTERNATIONAL WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-4628
Mailing Address - Country:US
Mailing Address - Phone:971-206-5200
Mailing Address - Fax:
Practice Address - Street 1:65 E UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-1091
Practice Address - Country:US
Practice Address - Phone:971-206-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REHAB SPECIALISTS OUTPATIENT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-25
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty