Basic Information
| Provider Information | |||||||||
| NPI: | 1841220670 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOME REHAB SOLUTIONS OF ST AUGUSTINE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3123 | ||||||||
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| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320853123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048244990 | ||||||||
| FaxNumber: | 9048242226 | ||||||||
| Practice Location | |||||||||
| Address1: | 965 SALTWATER CIR | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320806305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9045013044 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 08/19/2011 | ||||||||
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| AuthorizedOfficialLastName: | HEMELT | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
| AuthorizedOfficialMiddleName: | LEO | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9045013044 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.P.T., O.T.R./L | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT11336 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | PT21456 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 003256100 | 05 | FL | MEDICAID | Y107Q | 01 | FL | BCBS | OTHER |