Provider Demographics
NPI:1255948436
Name:PREMIER MEDICAL REHABILITATION SC
Entity type:Organization
Organization Name:PREMIER MEDICAL REHABILITATION SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:N
Authorized Official - Last Name:ROSALES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-986-4411
Mailing Address - Street 1:1820 WINDSOR RD
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-4271
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1820 WINDSOR RD
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-4271
Practice Address - Country:US
Practice Address - Phone:815-986-4411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty