Basic Information
Provider Information | |||||||||
NPI: | 1205879533 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KEYSTONE REHABILITATION SYSTEMS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NOVACARE REHABILITATION | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4714 GETTYSBURG RD | ||||||||
Address2: | LEGAL DEPT | ||||||||
City: | MECHANICSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 170554325 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7179721100 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 678 E TAGGART ST STE 104 | ||||||||
Address2: |   | ||||||||
City: | EAST PALESTINE | ||||||||
State: | OH | ||||||||
PostalCode: | 444132422 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3304269998 | ||||||||
FaxNumber: | 3304269447 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2006 | ||||||||
LastUpdateDate: | 09/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TARVIN | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT & SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 7179721100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 261QR0400X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 225100000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.