Provider Demographics
NPI:1114903234
Name:REHAB UNLIMITED AT SOUTHBRIDGE, LLC
Entity type:Organization
Organization Name:REHAB UNLIMITED AT SOUTHBRIDGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:YANKUSH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:330-726-0151
Mailing Address - Street 1:725 BOARDMAN CANFIELD RD
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4380
Mailing Address - Country:US
Mailing Address - Phone:330-726-0151
Mailing Address - Fax:330-726-6540
Practice Address - Street 1:725 BOARDMAN CANFIELD RD
Practice Address - Street 2:SUITE A-1
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4380
Practice Address - Country:US
Practice Address - Phone:330-726-0151
Practice Address - Fax:330-726-6540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-6707261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2240560Medicaid
OH2240560Medicaid