Provider Demographics
NPI:1801865399
Name:JLC REHAB, INC.
Entity Type:Organization
Organization Name:JLC REHAB, INC.
Other - Org Name:INDIGO PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:J
Authorized Official - Last Name:KLIXBULL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:843-357-4039
Mailing Address - Street 1:11931 PLAZA DR
Mailing Address - Street 2:PO BOX 1795
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-9356
Mailing Address - Country:US
Mailing Address - Phone:843-357-4039
Mailing Address - Fax:843-357-4227
Practice Address - Street 1:11931 PLAZA DR
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-9356
Practice Address - Country:US
Practice Address - Phone:843-357-4039
Practice Address - Fax:843-357-4227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5347225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2523Medicaid
SCGP2523Medicaid