Provider Demographics
NPI:1215950696
Name:IN- HOME REHAB SOUTHEASTERN
Entity type:Organization
Organization Name:IN- HOME REHAB SOUTHEASTERN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-331-4397
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:WI
Mailing Address - Zip Code:53167-0367
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:102 NORTH STATE STREET
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:WI
Practice Address - Zip Code:53167
Practice Address - Country:US
Practice Address - Phone:262-331-4397
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5627225100000X
WI4088026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========019OtherBLUE CROSS BLUE SHIELD WI
WI=========019OtherBLUE CROSS BLUE SHIELD WI