Provider Demographics
NPI:1457420648
Name:MUKWONAGO RAMILY REHABILITATION CLINIC, LLC
Entity Type:Organization
Organization Name:MUKWONAGO RAMILY REHABILITATION CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HEBAR
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:262-363-3014
Mailing Address - Street 1:PO BOX 192
Mailing Address - Street 2:727 HWY NN
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-0192
Mailing Address - Country:US
Mailing Address - Phone:262-363-3014
Mailing Address - Fax:
Practice Address - Street 1:727 COUNTY ROAD NN E
Practice Address - Street 2:
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-1011
Practice Address - Country:US
Practice Address - Phone:262-363-3014
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3044225100000X
WI3746225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty