Provider Demographics
NPI:1629081906
Name:KEWANEE PHYSICAL THERAPY AND REHAB SPECIALISTS LLC
Entity Type:Organization
Organization Name:KEWANEE PHYSICAL THERAPY AND REHAB SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRIAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-552-2996
Mailing Address - Street 1:PO BOX 3497
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-3497
Mailing Address - Country:US
Mailing Address - Phone:877-552-2996
Mailing Address - Fax:866-245-8064
Practice Address - Street 1:1258 W SOUTH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-8300
Practice Address - Country:US
Practice Address - Phone:866-932-5400
Practice Address - Fax:309-932-8105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070009875225100000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209860Medicare ID - Type Unspecified
IL5272470002Medicare NSC