Provider Demographics
NPI:1710718804
Name:POWERBACK REHAB
Entity type:Organization
Organization Name:POWERBACK REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPT
Authorized Official - Prefix:
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:
Authorized Official - Last Name:AVERY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:618-554-2907
Mailing Address - Street 1:4115 STATE ROAD 91 APT 207
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-9224
Mailing Address - Country:US
Mailing Address - Phone:618-554-2907
Mailing Address - Fax:
Practice Address - Street 1:4115 STATE ROAD 91 APT 207
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-9224
Practice Address - Country:US
Practice Address - Phone:618-554-2907
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health