Provider Demographics
NPI:1609934660
Name:COLLIER REHABILITATION SYSTEMS
Entity Type:Organization
Organization Name:COLLIER REHABILITATION SYSTEMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:CPO
Authorized Official - Phone:925-943-1119
Mailing Address - Street 1:3161 PUTNAM BLVD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-4650
Mailing Address - Country:US
Mailing Address - Phone:925-943-1119
Mailing Address - Fax:925-943-2493
Practice Address - Street 1:3161 PUTNAM BLVD
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-4650
Practice Address - Country:US
Practice Address - Phone:925-943-1119
Practice Address - Fax:925-943-2493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0000026982335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXB0009910OtherMEDI-CAL
CA0244140001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER