Provider Demographics
NPI:1255776613
Name:CEDAR GROVE REHAB LLC
Entity type:Organization
Organization Name:CEDAR GROVE REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTORNEY
Authorized Official - Prefix:MR
Authorized Official - First Name:OTIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:770-940-4975
Mailing Address - Street 1:3395 BOULDERCREST RD
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-1639
Mailing Address - Country:US
Mailing Address - Phone:404-241-3280
Mailing Address - Fax:
Practice Address - Street 1:3395 BOULDERCREST RD
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-1639
Practice Address - Country:US
Practice Address - Phone:404-241-3280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty