Provider Demographics
NPI:1588848618
Name:SOUTHEAST REHABILITATION, LLC
Entity Type:Organization
Organization Name:SOUTHEAST REHABILITATION, LLC
Other - Org Name:POPLAR BLUFF REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KYLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-712-2280
Mailing Address - Street 1:PO BOX 3
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902-0003
Mailing Address - Country:US
Mailing Address - Phone:573-712-2280
Mailing Address - Fax:
Practice Address - Street 1:3999 HWY PP
Practice Address - Street 2:SUITE 2
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901
Practice Address - Country:US
Practice Address - Phone:573-712-2280
Practice Address - Fax:573-778-9589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000015661Medicare PIN