Healthcare Provider Details

I. General information

NPI: 1073174082
Provider Name (Legal Business Name): FERNANDINA BEACH REHAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2019
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 LIME ST
FERNANDINA BEACH FL
32034-3017
US

IV. Provider business mailing address

1000 GATES AVE
BROOKLYN NY
11221-6295
US

V. Phone/Fax

Practice location:
  • Phone: 904-261-0771
  • Fax:
Mailing address:
  • Phone: 718-852-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL GUTMAN
Title or Position: AUTHORIZED SIGNER
Credential:
Phone: 718-852-7000