Provider Demographics
NPI:1770050668
Name:PRARIE STATE REHABILITATION, LLC
Entity type:Organization
Organization Name:PRARIE STATE REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:708-275-4087
Mailing Address - Street 1:12220 S CHEYENNE DR
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1654
Mailing Address - Country:US
Mailing Address - Phone:708-275-4087
Mailing Address - Fax:
Practice Address - Street 1:12220 S CHEYENNE DR
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1654
Practice Address - Country:US
Practice Address - Phone:708-275-4087
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty