Provider Demographics
NPI:1154595122
Name:CRESCENT PHYSICAL REHABILITATION, LLC
Entity type:Organization
Organization Name:CRESCENT PHYSICAL REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SIKANDER
Authorized Official - Middle Name:M
Authorized Official - Last Name:BAJWA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:314-616-1276
Mailing Address - Street 1:1519 VIRGINIA DR
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2046
Mailing Address - Country:US
Mailing Address - Phone:314-616-1276
Mailing Address - Fax:
Practice Address - Street 1:1519 VIRGINIA DR
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2046
Practice Address - Country:US
Practice Address - Phone:314-616-1276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-21
Last Update Date:2008-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC0531406261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation