Provider Demographics
NPI:1952591562
Name:TRI-STATE REHAB & WELNESS CENTER, LLC
Entity Type:Organization
Organization Name:TRI-STATE REHAB & WELNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ACKERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:812-673-4947
Mailing Address - Street 1:PO BOX 123
Mailing Address - Street 2:
Mailing Address - City:WADESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47638-0123
Mailing Address - Country:US
Mailing Address - Phone:812-673-4947
Mailing Address - Fax:812-673-4846
Practice Address - Street 1:7125 HWY 66
Practice Address - Street 2:
Practice Address - City:WADESVILLE
Practice Address - State:IN
Practice Address - Zip Code:47638-0123
Practice Address - Country:US
Practice Address - Phone:812-673-4947
Practice Address - Fax:812-673-4846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN6021870001Medicare NSC