Basic Information
| Provider Information | |||||||||
| NPI: | 1407523657 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REHAB SPECIALISTS OUTPATIENT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4560 SE INTERNATIONAL WAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972224628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712065200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 65 E UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852811091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712065200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2021 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
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| AuthorizedOfficialLastName: | FOGG | ||||||||
| AuthorizedOfficialFirstName: | PHILLIP | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9712065200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | REHAB SPECIALISTS OUTPATIENT LLC | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.