1710538319 NPI number — FIRST STATE SPINAL 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 1710538319 NPI number — FIRST STATE SPINAL REHABILITATION LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIRST STATE SPINAL 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:
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:
1710538319
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9044 SE BRIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOBE SOUND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33455-5313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-546-9591
Provider Business Mailing Address Fax Number:
772-546-9535

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 W 4TH ST STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19805-3352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-546-9591
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/25/2019

Additional Information

Authorized Official

Authorized Official Last Name:
WAKULA
Authorized Official First Name:
JENEANE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
772-546-9591

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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