Provider Demographics
NPI:1871966382
Name:KIRBY REHABILITATION, INC
Entity type:Organization
Organization Name:KIRBY REHABILITATION, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:LEA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-614-4002
Mailing Address - Street 1:723 W. 111TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628
Mailing Address - Country:US
Mailing Address - Phone:773-614-4002
Mailing Address - Fax:773-453-3262
Practice Address - Street 1:723 W. 111TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628
Practice Address - Country:US
Practice Address - Phone:773-614-4002
Practice Address - Fax:773-453-3262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILCA8419-0001261QR0405X
ILA21780002A251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCA8419-0001Medicaid