Basic Information
Provider Information | |||||||||
NPI: | 1003835026 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADVANCE REHAB & HOME HEALTH LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2316 W 23RD ST STE B | ||||||||
Address2: |   | ||||||||
City: | PANAMA CITY | ||||||||
State: | FL | ||||||||
PostalCode: | 324052373 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8505224770 | ||||||||
FaxNumber: | 8505224760 | ||||||||
Practice Location | |||||||||
Address1: | 2316 W 23RD ST STE B | ||||||||
Address2: |   | ||||||||
City: | PANAMA CITY | ||||||||
State: | FL | ||||||||
PostalCode: | 324052373 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8505224770 | ||||||||
FaxNumber: | 8505224760 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2006 | ||||||||
LastUpdateDate: | 03/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HUSSEIN | ||||||||
AuthorizedOfficialFirstName: | MOHAMED | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 8505224770 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PT | ||||||||
NPICertificationDate: | 03/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT8384 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225X00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
ID Information
ID | Type | State | Issuer | Description | Q6A | 01 | FL | BCBS OF FL | OTHER | 891217300 | 05 | FL |   | MEDICAID | BCBS INDUVIDUAL NUMB | 01 | FL | Y6894 | OTHER |