1598785107 NPI number — PROSPECT REHABILITATION, PC

Table of content: (NPI 1598785107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598785107 NPI number — PROSPECT REHABILITATION, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROSPECT REHABILITATION, PC
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:
JOHN M. DIBLASIO DBA PROSPECT REHABILITATION
Provider Other Organization Name Type Code:
4
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:
1598785107
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1365
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANCHESTER CENTER
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-362-1151
Provider Business Mailing Address Fax Number:
802-362-7046

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7254 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANCHESTER CENTER
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-362-1151
Provider Business Practice Location Address Fax Number:
802-362-7046
Provider Enumeration Date:
07/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DIBLASIO
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PHYSICAL THERAPIST/OWNER
Authorized Official Telephone Number:
802-362-1151

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  040-0003139 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: OVN3061 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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