1487723359 NPI number — CREATIVE REHAB, INC.

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 1487723359 NPI number — CREATIVE REHAB, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREATIVE 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:
Provider Other Organization Name Type Code:
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:
1487723359
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:
4835 KINGSWAY WEST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GURNEE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60031-5705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-599-9171
Provider Business Mailing Address Fax Number:
847-599-9124

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 S GREENLEAF ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
GURNEE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60031-5705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-599-9171
Provider Business Practice Location Address Fax Number:
847-599-9124
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIDSON
Authorized Official First Name:
ANITA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNNER
Authorized Official Telephone Number:
847-599-9171

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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