1205965175 NPI number — INDUSTRIAL WELLNESS REHAB, INC

Table of content: (NPI 1205965175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205965175 NPI number — INDUSTRIAL WELLNESS REHAB, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDUSTRIAL WELLNESS REHAB, INC
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:
IWR THERAPY SYSTEMS
Provider Other Organization Name Type Code:
5
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:
1205965175
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2048 S BROAD ST # A
Provider Second Line Business Mailing Address:
BROOKLEY COMPLEX
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36615-1285
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-433-1414
Provider Business Mailing Address Fax Number:
251-433-9634

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
627 HIGHWAY 43 SOUTH
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SARALAND
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-675-3390
Provider Business Practice Location Address Fax Number:
251-675-9976
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SULLIVAN
Authorized Official First Name:
LISA
Authorized Official Middle Name:
W
Authorized Official Title or Position:
VP-ACCTS RECEIVABLE MANAGER
Authorized Official Telephone Number:
251-586-0067

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PTH1919 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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