Provider Demographics
NPI:1750312849
Name:TALLASSEE REHAB PC
Entity type:Organization
Organization Name:TALLASSEE REHAB PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN ETTEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:334-799-5853
Mailing Address - Street 1:1000 FRIENDSHIP RD
Mailing Address - Street 2:
Mailing Address - City:TALLASSEE
Mailing Address - State:AL
Mailing Address - Zip Code:36078-1265
Mailing Address - Country:US
Mailing Address - Phone:334-283-8032
Mailing Address - Fax:334-283-1136
Practice Address - Street 1:1000 FRIENDSHIP RD
Practice Address - Street 2:
Practice Address - City:TALLASSEE
Practice Address - State:AL
Practice Address - Zip Code:36078-1265
Practice Address - Country:US
Practice Address - Phone:334-283-8032
Practice Address - Fax:334-283-1136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1487373OtherCIGNA
168028100OtherUS DEPT OF LABOR OWCP ACS
382573OtherACN GROUP
AL1054269OtherFIRST HEALTH
AL45311OtherHEALTHSPRING OF AL
AL6410033OtherUNITED HEALTHCARE
AL529907700Medicaid