Provider Demographics
NPI:1891307112
Name:PROVIDENCE REHAB GROUP, INC.
Entity Type:Organization
Organization Name:PROVIDENCE REHAB GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:RUEL
Authorized Official - Middle Name:WARRINER
Authorized Official - Last Name:ABIAD
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:415-225-0126
Mailing Address - Street 1:PO BOX 5215
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-5215
Mailing Address - Country:US
Mailing Address - Phone:415-225-0126
Mailing Address - Fax:415-223-9513
Practice Address - Street 1:3230 CARLSON BLVD
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-3907
Practice Address - Country:US
Practice Address - Phone:510-525-3212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty