Provider Demographics
NPI:1922421908
Name:REAGAN REHABILITATION OUTPATIENT THERAPY, LLC
Entity Type:Organization
Organization Name:REAGAN REHABILITATION OUTPATIENT THERAPY, LLC
Other - Org Name:REAGAN REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/STAFF THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:DW
Authorized Official - Last Name:REAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:855-786-8782
Mailing Address - Street 1:217 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-2553
Mailing Address - Country:US
Mailing Address - Phone:855-786-8782
Mailing Address - Fax:
Practice Address - Street 1:217 NORTH ST
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-2553
Practice Address - Country:US
Practice Address - Phone:855-786-8782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001015007225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty