1801342001 NPI number — PREMIER THERAPY AND REHAB

Table of content: (NPI 1801342001)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801342001 NPI number — PREMIER THERAPY AND REHAB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER THERAPY AND REHAB
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:
1801342001
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10611 NW SR 20
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRISTOL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32321-3441
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-591-4737
Provider Business Mailing Address Fax Number:
850-254-9901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10611 NW STATE ROAD 20
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32321-3441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-591-4737
Provider Business Practice Location Address Fax Number:
850-254-9901
Provider Enumeration Date:
08/28/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BYLER
Authorized Official First Name:
TESSA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
850-591-4737

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  OT 16505 , 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: 018620800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com