Provider Demographics
NPI:1942537188
Name:KINETIC REHAB LLC
Entity Type:Organization
Organization Name:KINETIC REHAB LLC
Other - Org Name:CORK PHYSICAL THERAPY
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:M
Authorized Official - Last Name:RHOADS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-826-2365
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:410 N SECOND STREET
Mailing Address - City:MARSHALL
Mailing Address - State:IL
Mailing Address - Zip Code:62441-0040
Mailing Address - Country:US
Mailing Address - Phone:217-826-2365
Mailing Address - Fax:217-826-8120
Practice Address - Street 1:410 N 2ND ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:IL
Practice Address - Zip Code:62441-1010
Practice Address - Country:US
Practice Address - Phone:217-826-2365
Practice Address - Fax:217-826-8120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-09
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070002318225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1232012OtherBLUE CROSS KINETIC
ILIL2959Medicare PIN