Basic Information
Provider Information | |||||||||
NPI: | 1831815430 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROYAL PALM BEACH REHAB CORP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4971 LE CHALET BLVD STE 100 | ||||||||
Address2: |   | ||||||||
City: | BOYNTON BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334361418 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5615374526 | ||||||||
FaxNumber: | 5616343449 | ||||||||
Practice Location | |||||||||
Address1: | 579 NW LAKE WHITNEY PL STE 101 | ||||||||
Address2: |   | ||||||||
City: | PORT ST LUCIE | ||||||||
State: | FL | ||||||||
PostalCode: | 349861622 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5615374526 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/14/2022 | ||||||||
LastUpdateDate: | 10/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GARCIA | ||||||||
AuthorizedOfficialFirstName: | JORGE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 5615374526 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 111N00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor |   |
No ID Information.