1306307178 NPI number — HIGHWAY 30 PHYSICAL THERAPY AND REHABILITATION, LLC

Table of content: (NPI 1306307178)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306307178 NPI number — HIGHWAY 30 PHYSICAL THERAPY AND REHABILITATION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HIGHWAY 30 PHYSICAL THERAPY AND REHABILITATION, 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:
1306307178
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 W. 89TH AVENUE
Provider Second Line Business Mailing Address:
SUITE W4
Provider Business Mailing Address City Name:
MERRIVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46410-7050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-648-2041
Provider Business Mailing Address Fax Number:
219-472-0665

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
333 W. 89TH AVENUE
Provider Second Line Business Practice Location Address:
SUITE W4
Provider Business Practice Location Address City Name:
MERRIVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46410-7050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-648-2041
Provider Business Practice Location Address Fax Number:
219-472-0665
Provider Enumeration Date:
03/26/2019

Additional Information

Authorized Official

Authorized Official Last Name:
POMPONI
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
219-662-2278

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300027182 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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