Basic Information
| Provider Information | |||||||||
| NPI: | 1902996333 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORA HEALTH SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1110 SHAWNEE ROAD | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192216712 | ||||||||
| FaxNumber: | 4192220507 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 S FEDERAL HWY | ||||||||
| Address2: | |||||||||
| City: | DANIA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549205050 | ||||||||
| FaxNumber: | 9549207992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2006 | ||||||||
| LastUpdateDate: | 01/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | ROUSH | ||||||||
| AuthorizedOfficialFirstName: | BRAD | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4192216712 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CORA HEALTH SERVICES INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | 4378 | 01 | FL | TRS | OTHER | 884156059 | 05 | FL | MEDICAID | RN6 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |