Provider Demographics
NPI:1902014285
Name:INTEGRATIVE REHABMEDICINE SC
Entity Type:Organization
Organization Name:INTEGRATIVE REHABMEDICINE SC
Other - Org Name:MEDLUX REHAB & WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:ALFONZO
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MBA
Authorized Official - Phone:630-873-5425
Mailing Address - Street 1:345 EXECUTIVE PKWY STE M4
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5291
Mailing Address - Country:US
Mailing Address - Phone:815-381-8514
Mailing Address - Fax:
Practice Address - Street 1:345 EXECUTIVE PKWY STE M4
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5291
Practice Address - Country:US
Practice Address - Phone:815-381-8514
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1101662081H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative MedicineGroup - Multi-Specialty