Healthcare Provider Details

I. General information

NPI: 1780636878
Provider Name (Legal Business Name): SERVICE MEDICAL REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 W 16TH AVE SUITE 140 U
HIALEAH FL
33012-4654
US

IV. Provider business mailing address

3750 W 16TH AVE SUITE 140 U
HIALEAH FL
33012-4654
US

V. Phone/Fax

Practice location:
  • Phone: 305-826-5567
  • Fax: 305-826-5568
Mailing address:
  • Phone: 305-826-5567
  • Fax: 305-826-5568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number600195-2
License Number StateFL

VIII. Authorized Official

Name: MR. JUAN A NIEVES SR.
Title or Position: PRESIDENT
Credential:
Phone: 305-826-5567