Provider Demographics
NPI:1619031184
Name:JEFFERSON REHABILITATION AND WELLNESS LLC
Entity Type:Organization
Organization Name:JEFFERSON REHABILITATION AND WELLNESS LLC
Other - Org Name:INTEGRATIVE PHYSICAL THERAPY CONCEPTS, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:LOREN
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:440-293-8654
Mailing Address - Street 1:42 S CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:OH
Mailing Address - Zip Code:44047-1311
Mailing Address - Country:US
Mailing Address - Phone:440-293-8654
Mailing Address - Fax:
Practice Address - Street 1:42 S CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:OH
Practice Address - Zip Code:44047-1311
Practice Address - Country:US
Practice Address - Phone:440-293-8654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT007159261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3028146Medicaid
OHP00415098OtherRAILROAD MEDICARE
OH000000517517OtherBLUE CROSS BLUE SHIELD
OH=========00OtherBUREAU OF WORKERS COMP
OH9366391Medicare PIN