Provider Demographics
NPI:1750421772
Name:THE REHABGYM INC
Entity type:Organization
Organization Name:THE REHABGYM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL/BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:JAQUES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-565-1422
Mailing Address - Street 1:373 BLAIR PARK RD UNIT 100
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-8077
Mailing Address - Country:US
Mailing Address - Phone:802-876-6000
Mailing Address - Fax:
Practice Address - Street 1:373 BLAIR PARK RD UNIT 100
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-8077
Practice Address - Country:US
Practice Address - Phone:802-876-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009754Medicaid
VT200070257OtherMVP GROUP #
VTCIGNAOtherGROUP #
VT00059461OtherBCBS GROUP #
VTDOL605524500OtherOWCP
VT1009754Medicaid
VT1009754Medicaid
VT5334940001Medicare NSC
VTDOL605524500OtherOWCP