1811185291 NPI number — UNIVERSITY REHABILITATION, LLC

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 1811185291 NPI number — UNIVERSITY REHABILITATION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY REHABILITATION, LLC
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:
UNIVERSITY REHABILITATION
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:
1811185291
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8600
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34985-8600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-335-7966
Provider Business Mailing Address Fax Number:
772-335-7963

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
733 DUNLAWTON AVE
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
PORT ORANGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32127-4225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-756-0077
Provider Business Practice Location Address Fax Number:
386-756-6811
Provider Enumeration Date:
10/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TUCKER
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER/PT
Authorized Official Telephone Number:
386-756-0077

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT 4660 , 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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