Provider Demographics
NPI:1497842033
Name:WORKSPORT REHABILITATION SERVICE
Entity Type:Organization
Organization Name:WORKSPORT REHABILITATION SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:574-231-8950
Mailing Address - Street 1:411 E IRELAND RD STE 400
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-2681
Mailing Address - Country:US
Mailing Address - Phone:574-231-8950
Mailing Address - Fax:574-231-8955
Practice Address - Street 1:411 E IRELAND RD STE 400
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2681
Practice Address - Country:US
Practice Address - Phone:574-231-8950
Practice Address - Fax:574-231-8955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05002570A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000093552OtherBC BS PROVIDER NUMBER
IN135250Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER