Basic Information
| Provider Information | |||||||||
| NPI: | 1104995406 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORA REHABILITATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4345 WOODSTOCK DR | ||||||||
| Address2: | UNIT B | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334092602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613711151 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6901 OKEECHOBEE BLVD | ||||||||
| Address2: | E2 | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334112511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614783702 | ||||||||
| FaxNumber: | 5614783703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PUCCIO | ||||||||
| AuthorizedOfficialFirstName: | JOHNNIE | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPY ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 5614783702 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | PTA, LMT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | PTA19316 | FL | Y | Managed Care Organizations | Preferred Provider Organization |
No ID Information.