Provider Demographics
NPI:1154693653
Name:REKLAW DIVERSIFIED LLC
Entity type:Organization
Organization Name:REKLAW DIVERSIFIED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-371-0039
Mailing Address - Street 1:120 12TH STREET EXT
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2352
Mailing Address - Country:US
Mailing Address - Phone:304-487-8000
Mailing Address - Fax:304-487-5666
Practice Address - Street 1:120 12TH STREET EXT
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2352
Practice Address - Country:US
Practice Address - Phone:304-487-8000
Practice Address - Fax:304-487-5666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-31
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24684273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1255309910Medicare UPIN