Provider Demographics
NPI:1194114553
Name:EAST BROAD PHYSICAL REHAB LLC
Entity type:Organization
Organization Name:EAST BROAD PHYSICAL REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:440-376-3141
Mailing Address - Street 1:6495 E BROAD ST
Mailing Address - Street 2:STE I
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1541
Mailing Address - Country:US
Mailing Address - Phone:614-868-1232
Mailing Address - Fax:614-868-8308
Practice Address - Street 1:6495 E BROAD ST
Practice Address - Street 2:STE I
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1541
Practice Address - Country:US
Practice Address - Phone:614-868-1232
Practice Address - Fax:614-868-8308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4170111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH033310Medicare UPIN