1093715773 NPI number — EVANS REHABILITATION SERVICES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093715773 NPI number — EVANS REHABILITATION SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVANS REHABILITATION SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LAKE OCONEE REHABILITATION AND PERFORMANCE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093715773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 TOWN PARK BLVD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-868-1707
Provider Business Mailing Address Fax Number:
706-868-1351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 TOWN PARK BLVD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
EVANS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-868-1707
Provider Business Practice Location Address Fax Number:
706-868-1351
Provider Enumeration Date:
07/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LOTT
Authorized Official First Name:
JASON
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
706-868-1707

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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