Basic Information
Provider Information | |||||||||
NPI: | 1962501379 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | H2 REHABILITATION SERVICES OF FLORIDA LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | H2 HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 554 KINGSLEY AVE | ||||||||
Address2: |   | ||||||||
City: | ORANGE PARK | ||||||||
State: | FL | ||||||||
PostalCode: | 320734830 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9045053081 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 405 11TH STREET | ||||||||
Address2: | SUITE 103 | ||||||||
City: | LIVE OAK | ||||||||
State: | FL | ||||||||
PostalCode: | 320643161 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3863645051 | ||||||||
FaxNumber: | 3863643741 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2006 | ||||||||
LastUpdateDate: | 04/15/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STREETER | ||||||||
AuthorizedOfficialFirstName: | AMANDA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9045053081 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/15/2020 |
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 | 8845212-09 | 05 | FL |   | MEDICAID | 4477946 | 01 | FL | AETNA NON-HMO | OTHER | 102701 | 01 | FL | AVMED | OTHER | 4511267 | 01 | FL | CIGNA | OTHER | QD4 | 01 | FL | BCBS | OTHER | 028575700 | 05 | FL |   | MEDICAID | 160630521 | 01 | FL | DEPARTMENT OF LABOR | OTHER |