1336538578 NPI number — WELLSPRING REHABILITATION SERVICES LLC

Table of content: (NPI 1336538578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336538578 NPI number — WELLSPRING REHABILITATION SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLSPRING REHABILITATION SERVICES 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:
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:
1336538578
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1124 SE 1ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47713-1322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-760-0709
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
255 W MAIN ST APT E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ISLAND
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42350-2179
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-760-7090
Provider Business Practice Location Address Fax Number:
812-205-2425
Provider Enumeration Date:
01/12/2015

Additional Information

Authorized Official

Authorized Official Last Name:
EVANS
Authorized Official First Name:
SHEILA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
812-760-0709

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100593640 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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