Provider Demographics
NPI:1629691639
Name:PROREHAB PC
Entity Type:Organization
Organization Name:PROREHAB PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANANGER
Authorized Official - Prefix:
Authorized Official - First Name:JUANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANADOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-575-1980
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6250
Mailing Address - Fax:630-575-7450
Practice Address - Street 1:603 S BISHOP AVE STE B
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-4320
Practice Address - Country:US
Practice Address - Phone:573-202-6537
Practice Address - Fax:573-426-7001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROREHAB PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty