Provider Demographics
NPI:1467686121
Name:BROAD ST PHYSICAL REHAB LLC
Entity Type:Organization
Organization Name:BROAD ST PHYSICAL REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-725-4720
Mailing Address - Street 1:3072 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-1302
Mailing Address - Country:US
Mailing Address - Phone:614-725-4720
Mailing Address - Fax:614-725-0787
Practice Address - Street 1:3072 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-1302
Practice Address - Country:US
Practice Address - Phone:614-725-4720
Practice Address - Fax:614-725-0787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-11
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1689111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty