Healthcare Provider Details

I. General information

NPI: 1588942882
Provider Name (Legal Business Name): STAFFREHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 08/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 BIRCH ST 3000 WEST TOWER
NEWPORT BEACH CA
92660-2127
US

IV. Provider business mailing address

5000 BIRCH ST 3000 WEST TOWER
NEWPORT BEACH CA
92660-2127
US

V. Phone/Fax

Practice location:
  • Phone: 188-883-5089
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number103693
License Number StateMN

VIII. Authorized Official

Name: LATASHA LYNN-DIONYSIUS LARSON
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTR/L
Phone: 320-293-3205