1972719128 NPI number — PHYSIOCORE FITNESS & REHAB., INC.

Table of content: (NPI 1972719128)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972719128 NPI number — PHYSIOCORE FITNESS & REHAB., INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSIOCORE FITNESS & 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:
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:
1972719128
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1565 SUNSET DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORAL GABLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33143-5528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-668-9108
Provider Business Mailing Address Fax Number:
305-668-9109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1565 SUNSET DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORAL GABLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
11343-5642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-271-3033
Provider Business Practice Location Address Fax Number:
305-668-9109
Provider Enumeration Date:
05/15/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HERRERA
Authorized Official First Name:
DORYS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
305-668-9108

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  18986 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251N0400X , with the licence number: 18986 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251S0007X , with the licence number: 18986 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251X0800X , with the licence number: 18986 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 18986 . This is a "PHYSICAL THERAPIST" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".