1912655291 NPI number — GREAT STRIDES REHABILITATION INC.

Table of content: (NPI 1912655291)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912655291 NPI number — GREAT STRIDES REHABILITATION INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT STRIDES REHABILITATION 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:
6
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:
1912655291
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 932184
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31193-4912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3890 TURTLE CREEK DR STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ORANGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32127-9352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-488-3228
Provider Business Practice Location Address Fax Number:
904-404-7743
Provider Enumeration Date:
03/15/2022

Additional Information

Authorized Official

Authorized Official Last Name:
STREETER
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF ADMINISTRATIVE OFFICER
Authorized Official Telephone Number:
800-699-9395

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 111641503 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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