Provider Demographics
NPI:1285740621
Name:KEWANEE PHYSICAL THERAPY AND REHAB SPECIALISTS
Entity type:Organization
Organization Name:KEWANEE PHYSICAL THERAPY AND REHAB SPECIALISTS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:DEBORD
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MS, ATC, SCS
Authorized Official - Phone:309-695-4010
Mailing Address - Street 1:PO BOX 3497
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-0300
Mailing Address - Country:US
Mailing Address - Phone:877-552-2996
Mailing Address - Fax:262-898-8696
Practice Address - Street 1:101 S GALENA AVE
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:IL
Practice Address - Zip Code:61491-1470
Practice Address - Country:US
Practice Address - Phone:309-695-4010
Practice Address - Fax:309-852-2402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209860Medicare ID - Type Unspecified