Provider Demographics
NPI:1063152486
Name:VANDALIA REHAB LLC
Entity type:Organization
Organization Name:VANDALIA REHAB LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TENENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-613-5764
Mailing Address - Street 1:1837 EAST 33RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4425
Mailing Address - Country:US
Mailing Address - Phone:917-613-5764
Mailing Address - Fax:
Practice Address - Street 1:208 N CASSEL ROAD
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:OH
Practice Address - Zip Code:45377
Practice Address - Country:US
Practice Address - Phone:937-898-4202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-01
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility