Provider Demographics
NPI:1497063440
Name:SPINAL REHAB GROUP, LLC
Entity Type:Organization
Organization Name:SPINAL REHAB GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DODES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:617-524-4878
Mailing Address - Street 1:406 S HUNTINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4814
Mailing Address - Country:US
Mailing Address - Phone:617-524-4878
Mailing Address - Fax:617-524-0075
Practice Address - Street 1:406 S HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-4814
Practice Address - Country:US
Practice Address - Phone:617-524-4878
Practice Address - Fax:617-524-0075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1871261QR0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care