1083949861 NPI number — PERFORMANCE REHABILITATION OF WESTERN NEW ENGLAND LLC

Table of content: (NPI 1083949861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083949861 NPI number — PERFORMANCE REHABILITATION OF WESTERN NEW ENGLAND LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERFORMANCE REHABILITATION OF WESTERN NEW ENGLAND 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:
Provider Other Organization Name Type Code:
6
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:
1083949861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-296-2223
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
70 POST OFFICE PARK
Provider Second Line Business Practice Location Address:
SUITE 7007
Provider Business Practice Location Address City Name:
WILBRAHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01095-1287
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-279-1435
Provider Business Practice Location Address Fax Number:
413-279-1438
Provider Enumeration Date:
10/12/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MCGIVERN
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF COMPLIANCE OFFICER
Authorized Official Telephone Number:
630-296-2223

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251H1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XH1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 28117 . This is a "HEALTH NEW ENGLAND" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: AA49027 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: Y61264 . This is a "PT---BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9715568 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 972730 . This is a "NETWORK HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 103355100 . This is a "DEPT OF LABOR" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 64-04290 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: OG0011 . This is a "OT----BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9715568 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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