Provider Demographics
NPI:1679671119
Name:PROFESSIONAL REHABILITATION SERVICES, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL REHABILITATION SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PT, DPT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HENEBRY
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:636-528-6080
Mailing Address - Street 1:108 PROFESSIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-2823
Mailing Address - Country:US
Mailing Address - Phone:636-528-6080
Mailing Address - Fax:636-528-3973
Practice Address - Street 1:108 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-2823
Practice Address - Country:US
Practice Address - Phone:636-528-6080
Practice Address - Fax:636-528-3973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO990001512Medicare ID - Type UnspecifiedMEDICARE