Basic Information
| Provider Information | |||||||||
| NPI: | 1417023730 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLORIDA PHYSICAL THERAPY & REHABILITATIVE SERVICES INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LAKE CENTRE FOR REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 W NORTH BLVD | ||||||||
| Address2: | SUITE D | ||||||||
| City: | LEESBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347485063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527286636 | ||||||||
| FaxNumber: | 3527874522 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 W NORTH BLVD | ||||||||
| Address2: | SUITE D | ||||||||
| City: | LEESBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347485063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527286636 | ||||||||
| FaxNumber: | 3527874522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 04/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOLDSTEIN | ||||||||
| AuthorizedOfficialFirstName: | GERALD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3527286636 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | R39 | 01 | FL | BCBS | OTHER |