Provider Demographics
NPI:1952649659
Name:SPARTAN REHABILITATION, LLC
Entity Type:Organization
Organization Name:SPARTAN REHABILITATION, LLC
Other - Org Name:SPARTAN REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DOMINIC
Authorized Official - Middle Name:
Authorized Official - Last Name:KOULIANOS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:330-758-5533
Mailing Address - Street 1:6431 MAHONING AVE
Mailing Address - Street 2:2
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-2039
Mailing Address - Country:US
Mailing Address - Phone:330-651-6824
Mailing Address - Fax:330-609-5553
Practice Address - Street 1:6431 MAHONING AVE
Practice Address - Street 2:2
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-2039
Practice Address - Country:US
Practice Address - Phone:330-651-6824
Practice Address - Fax:330-609-5553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-30
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT8632261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2198643Medicaid
OH364513Medicare UPIN