Provider Demographics
NPI:1639221682
Name:PEDIATRIC REHABILITATION SERVICES
Entity Type:Organization
Organization Name:PEDIATRIC REHABILITATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:JOHNSON
Authorized Official - Last Name:MARUVAMA
Authorized Official - Suffix:
Authorized Official - Credentials:OTRL
Authorized Official - Phone:630-964-4707
Mailing Address - Street 1:5201 WALNUT AVENUE
Mailing Address - Street 2:STE 4
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-4025
Mailing Address - Country:US
Mailing Address - Phone:630-964-4707
Mailing Address - Fax:630-964-4797
Practice Address - Street 1:5201 WALNUT AVENUE
Practice Address - Street 2:STE 4
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-4025
Practice Address - Country:US
Practice Address - Phone:630-964-4707
Practice Address - Fax:630-964-4797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation