Provider Demographics
NPI:1477136133
Name:BROADBENT REHAB LLC
Entity Type:Organization
Organization Name:BROADBENT REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:W
Authorized Official - Last Name:BROADBENT
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:417-880-5002
Mailing Address - Street 1:3550 E DELMAR ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65809-1440
Mailing Address - Country:US
Mailing Address - Phone:417-880-5002
Mailing Address - Fax:
Practice Address - Street 1:3550 E DELMAR ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65809-1440
Practice Address - Country:US
Practice Address - Phone:417-880-5002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty