Provider Demographics
NPI:1649415217
Name:LAKE OCONEE REHABILITATION AND PERFORMANCE CENTER, LLC
Entity Type:Organization
Organization Name:LAKE OCONEE REHABILITATION AND PERFORMANCE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICIAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:PRELL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:706-454-1811
Mailing Address - Street 1:117 HARMONY CROSSING
Mailing Address - Street 2:SUITE 4
Mailing Address - City:EATONTON
Mailing Address - State:GA
Mailing Address - Zip Code:31024
Mailing Address - Country:US
Mailing Address - Phone:706-454-1811
Mailing Address - Fax:706-454-1812
Practice Address - Street 1:117 HARMONY CROSSING
Practice Address - Street 2:SUITE 4
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024
Practice Address - Country:US
Practice Address - Phone:706-454-1811
Practice Address - Fax:706-454-1812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G701137Medicare UPIN