1558315663 NPI number — MEDICAL & SPORTS REHABILITATION CENTER INC

Table of content: (NPI 1558315663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558315663 NPI number — MEDICAL & SPORTS REHABILITATION CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL & SPORTS REHABILITATION CENTER 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:
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:
1558315663
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
689 TAMIAMI TRL N
Provider Second Line Business Mailing Address:
STE E
Provider Business Mailing Address City Name:
NAPLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34102-8100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-261-0291
Provider Business Mailing Address Fax Number:
239-261-0678

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
661 GOODLETTE RD N
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
NAPLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34102-5609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-261-4592
Provider Business Practice Location Address Fax Number:
239-261-0716
Provider Enumeration Date:
05/22/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
YURKOVAC
Authorized Official First Name:
BETH
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
239-261-0291

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XH1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: PT0001402 . This is a "PT LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: PT0004535 . This is a "PT LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: R32 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: OT6930 . This is a "OT LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: OT9990 . This is a "OT LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: PT21393 . This is a "PT LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: OT8618 . This is a "OT LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".