Provider Demographics
NPI:1306307178
Name:HIGHWAY 30 PHYSICAL THERAPY AND REHABILITATION, LLC
Entity type:Organization
Organization Name:HIGHWAY 30 PHYSICAL THERAPY AND REHABILITATION, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:POMPONI
Authorized Official - Suffix:
Authorized Official - Credentials:DO, FAAOS
Authorized Official - Phone:219-662-2278
Mailing Address - Street 1:333 W. 89TH AVENUE
Mailing Address - Street 2:SUITE W4
Mailing Address - City:MERRIVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7050
Mailing Address - Country:US
Mailing Address - Phone:219-648-2041
Mailing Address - Fax:219-472-0665
Practice Address - Street 1:333 W. 89TH AVENUE
Practice Address - Street 2:SUITE W4
Practice Address - City:MERRIVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7050
Practice Address - Country:US
Practice Address - Phone:219-648-2041
Practice Address - Fax:219-472-0665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-26
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300027182Medicaid