Provider Demographics
NPI:1699821058
Name:CENTER FOR INDEPEND REHAB
Entity Type:Organization
Organization Name:CENTER FOR INDEPEND REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:G
Authorized Official - Last Name:ROGES
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:209-845-8231
Mailing Address - Street 1:693 HI TECH PARKWAY
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361
Mailing Address - Country:US
Mailing Address - Phone:209-845-8231
Mailing Address - Fax:209-845-2883
Practice Address - Street 1:1134 PLUMAS STREET
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991
Practice Address - Country:US
Practice Address - Phone:530-822-9400
Practice Address - Fax:530-674-9744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225000000X
CA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0246970007Medicare NSC