Provider Demographics
NPI:1710145784
Name:PEDIATRIC REHAB SERVICES, PC
Entity Type:Organization
Organization Name:PEDIATRIC REHAB SERVICES, PC
Other - Org Name:PEDIATRIC REHAB SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:SKODA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-756-7356
Mailing Address - Street 1:9282 INGLESIDE FARM N
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38139-6719
Mailing Address - Country:US
Mailing Address - Phone:901-756-7356
Mailing Address - Fax:901-756-1349
Practice Address - Street 1:9282 INGLESIDE FARM N
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38139-6719
Practice Address - Country:US
Practice Address - Phone:901-756-7356
Practice Address - Fax:901-756-1349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3074225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty