Provider Demographics
NPI:1578612297
Name:ROCKY MOUNT REHABILITATION ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:ROCKY MOUNT REHABILITATION ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE PROPRIETOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:TANANIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:252-451-3734
Mailing Address - Street 1:2400 MEDPARK DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-2289
Mailing Address - Country:US
Mailing Address - Phone:252-451-3734
Mailing Address - Fax:252-451-3737
Practice Address - Street 1:2400 MEDPARK DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-2289
Practice Address - Country:US
Practice Address - Phone:252-451-3734
Practice Address - Fax:252-451-3737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891197MMedicaid
2272858BMedicare PIN
NCG32607Medicare UPIN