Basic Information
| Provider Information | |||||||||
| NPI: | 1881645695 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDUSTRIAL REHABILITATION CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEALTH AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 JACKSON PIKE | ||||||||
| Address2: | |||||||||
| City: | GALLIPOLIS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456311560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404465387 | ||||||||
| FaxNumber: | 7404465982 | ||||||||
| Practice Location | |||||||||
| Address1: | 313 MACCORKLE AVE SW | ||||||||
| Address2: | |||||||||
| City: | SOUTH CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253031263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047442300 | ||||||||
| FaxNumber: | 3047448195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 07/16/2009 | ||||||||
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| AuthorizedOfficialLastName: | RUSSELL-MASH | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7404465551 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 1036280001 | 01 | WV | MEDICARE DMERC | OTHER | 2219576 | 05 | WV | MEDICAID |