Basic Information
| Provider Information | |||||||||
| NPI: | 1548407521 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINT AUGUSTINE REHABILITATION SPECIALISTS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 MARINER HEALTH WAY STE 213 | ||||||||
| Address2: | |||||||||
| City: | SAINT AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320863251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042174259 | ||||||||
| FaxNumber: | 9042174251 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 MARINER HEALTH WAY | ||||||||
| Address2: | STE 213 | ||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320863251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042174259 | ||||||||
| FaxNumber: | 9042174251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2009 | ||||||||
| LastUpdateDate: | 04/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | LOMAGLIO | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9042174259 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
| NPICertificationDate: | 04/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | PT22437 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | PT22437 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 001451900 | 05 | FL | MEDICAID | Y902D | 01 | FL | BCBS | OTHER | DP7316 | 01 | FL | RR MEDICARE | OTHER |