Provider Demographics
NPI:1134360555
Name:WILKES REHAB LLC
Entity type:Organization
Organization Name:WILKES REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:WALLACE
Authorized Official - Last Name:WILKES
Authorized Official - Suffix:
Authorized Official - Credentials:MSOT
Authorized Official - Phone:478-668-3428
Mailing Address - Street 1:1350 BAY SPRINGS CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:GA
Mailing Address - Zip Code:31002-4247
Mailing Address - Country:US
Mailing Address - Phone:478-668-3428
Mailing Address - Fax:478-668-3428
Practice Address - Street 1:1350 BAY SPRINGS CHURCH RD
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:GA
Practice Address - Zip Code:31002-4247
Practice Address - Country:US
Practice Address - Phone:478-668-3428
Practice Address - Fax:478-668-3428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-14
Last Update Date:2009-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004805261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1508005901OtherINDIVIDUAL NPI