Provider Demographics
NPI:1760476618
Name:REHABILITATIVE PRODUCTS & NUTRITIONAL SUPPLY,INC.
Entity Type:Organization
Organization Name:REHABILITATIVE PRODUCTS & NUTRITIONAL SUPPLY,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:D
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-445-7470
Mailing Address - Street 1:11736 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-4732
Mailing Address - Country:US
Mailing Address - Phone:773-445-7482
Mailing Address - Fax:773-445-7522
Practice Address - Street 1:11736 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-4732
Practice Address - Country:US
Practice Address - Phone:773-445-7482
Practice Address - Fax:773-445-7522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid