1144222464 NPI number — M & M REHAB INC

Table of content: (NPI 1144222464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144222464 NPI number — M & M REHAB INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
M & M 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:
MID-FLORIDA PROSTHETICS & ORTHOTICS
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:
1144222464
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2300 SE 17TH ST
Provider Second Line Business Mailing Address:
STE 401
Provider Business Mailing Address City Name:
OCALA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34471-9140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-351-3207
Provider Business Mailing Address Fax Number:
352-351-3267

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9401 SW HIGHWAY 200
Provider Second Line Business Practice Location Address:
BLDG 400 SUITE 404
Provider Business Practice Location Address City Name:
OCALA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34481-9612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-873-0925
Provider Business Practice Location Address Fax Number:
352-351-3267
Provider Enumeration Date:
06/01/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BUSTAMANTE
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
352-331-3399

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  POR89 , 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)

  • Identifier: 012496900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".