Basic Information
| Provider Information | |||||||||
| NPI: | 1669980983 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FIVE STAR REHABILITATION AND WELLNESS SERVICES, LLC | ||||||||
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| OtherOrganizationName: | AGEILITY PHYSICAL THERAPY SOLUTIONS AT CORAL OAKS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 WASHINGTON ST STE 230 | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024581644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177968387 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 WEST LAKE ROAD | ||||||||
| Address2: | |||||||||
| City: | PALM HARBOR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346843142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277873333 | ||||||||
| FaxNumber: | 7277843430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2018 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | LEER | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6177968387 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FIVE STAR REHABILITATION AND WELLNESS SERVICES, LLC | ||||||||
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| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.