Provider Demographics
NPI:1639622699
Name:REHABONE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:REHABONE MEDICAL GROUP, INC.
Other - Org Name:REHABONE MEDICAL GROUP INC STE 4
Other - Org Type:Other Name
Authorized Official - Title/Position:NCPDP COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-636-9702
Mailing Address - Street 1:175 N JACKSON AVE
Mailing Address - Street 2:STE 109
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1909
Mailing Address - Country:US
Mailing Address - Phone:831-225-0209
Mailing Address - Fax:408-445-0875
Practice Address - Street 1:175 N JACKSON AVE
Practice Address - Street 2:STE 109
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1909
Practice Address - Country:US
Practice Address - Phone:831-225-0209
Practice Address - Fax:408-445-0875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-26
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74906208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty