Provider Demographics
NPI:1700482114
Name:PRAIRIE STATE REHAB, LLC
Entity type:Organization
Organization Name:PRAIRIE STATE REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:708-275-4087
Mailing Address - Street 1:711 S DEARBORN ST UNIT 705
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3820
Mailing Address - Country:US
Mailing Address - Phone:708-966-9283
Mailing Address - Fax:708-258-1632
Practice Address - Street 1:711 S DEARBORN ST UNIT 705
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3820
Practice Address - Country:US
Practice Address - Phone:708-966-9283
Practice Address - Fax:708-258-1632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty