Provider Demographics
NPI:1790126522
Name:MODERN REHAB
Entity Type:Organization
Organization Name:MODERN REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HULSEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:208-288-1155
Mailing Address - Street 1:1560 S CAROL ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1839
Mailing Address - Country:US
Mailing Address - Phone:208-288-1155
Mailing Address - Fax:208-288-0424
Practice Address - Street 1:745 S PROGRESS AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5619
Practice Address - Country:US
Practice Address - Phone:208-895-0309
Practice Address - Fax:208-895-0311
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REHABAUTHORITY LLC MBR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-07-09
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT 2949225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty