1104995406 NPI number — CORA REHABILITATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104995406 NPI number — CORA REHABILITATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORA REHABILITATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104995406
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4345 WOODSTOCK DR
Provider Second Line Business Mailing Address:
UNIT B
Provider Business Mailing Address City Name:
WEST PALM BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33409-2602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-371-1151
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6901 OKEECHOBEE BLVD
Provider Second Line Business Practice Location Address:
E2
Provider Business Practice Location Address City Name:
WEST PALM BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33411-2511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-478-3702
Provider Business Practice Location Address Fax Number:
561-478-3703
Provider Enumeration Date:
11/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PUCCIO
Authorized Official First Name:
JOHNNIE
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
PHYSICAL THERAPY ASSISTANT
Authorized Official Telephone Number:
561-478-3702

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X , with the licence number:  PTA19316 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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