Provider Demographics
NPI:1952346033
Name:INDEPENDENT REHABILITATION, INC.
Entity Type:Organization
Organization Name:INDEPENDENT REHABILITATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:THEODORE
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:909-886-6286
Mailing Address - Street 1:2037 N D ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-3936
Mailing Address - Country:US
Mailing Address - Phone:909-886-6286
Mailing Address - Fax:909-886-6186
Practice Address - Street 1:2037 N D ST
Practice Address - Street 2:SUITE 105
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405-3936
Practice Address - Country:US
Practice Address - Phone:909-886-6286
Practice Address - Fax:909-886-6186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT6249225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty