Basic Information
| Provider Information | |||||||||
| NPI: | 1881627073 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORA HEALTH SERVICES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CORA PHYSICAL THERAPY - MELBOURNE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1110 SHAWNEE RD | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458053529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192216712 | ||||||||
| FaxNumber: | 4192220507 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 W EAU GALLIE BLVD STE 105 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329353166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212552818 | ||||||||
| FaxNumber: | 3214099905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROUSH | ||||||||
| AuthorizedOfficialFirstName: | BRAD | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4192216712 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 60170391 | 01 | FL | FLIRIDA TRUE HEALTH | OTHER | 8841560-32 | 05 | FL | MEDICAID | QW4 | 01 | FL | BC/BS | OTHER |