1134378938 NPI number — PAIN RELIEF AND PHYSICAL REHAB INC

Table of content: (NPI 1134378938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134378938 NPI number — PAIN RELIEF AND PHYSICAL REHAB INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN RELIEF AND PHYSICAL REHAB INC
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:
PAIN RELIEF AND PHYSICAL REHAB
Provider Other Organization Name Type Code:
3
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:
1134378938
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9705 COMMERCE CENTER CT STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33908-3767
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-437-9313
Provider Business Mailing Address Fax Number:
239-245-8060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4977 ROYAL GULF CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33966-7006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-226-0077
Provider Business Practice Location Address Fax Number:
239-489-0077
Provider Enumeration Date:
09/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SUSKO
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
239-226-0077

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 17033 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2658666-00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 17033X . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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