Healthcare Provider Details

I. General information

NPI: 1699727156
Provider Name (Legal Business Name): FUNCTIONAL REHAB OF EAST FT. MYERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14630 PALM BEACH BLVD SUITE 6
FORT MYERS FL
33905-2333
US

IV. Provider business mailing address

PO BOX 2565
FORT MYERS FL
33902-2565
US

V. Phone/Fax

Practice location:
  • Phone: 239-690-3100
  • Fax: 239-693-3200
Mailing address:
  • Phone: 239-690-3100
  • Fax: 239-693-3200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 7037
License Number StateFL

VIII. Authorized Official

Name: DR. DIEGO DIAZ SAUSA JR.
Title or Position: PRESIDENT
Credential: MA, D.P.T.
Phone: 239-850-1891