Healthcare Provider Details

I. General information

NPI: 1326504614
Provider Name (Legal Business Name): FORGED PERFORMANCE AND REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5153 COCOPLUM AVE
MELBOURNE FL
32940-1400
US

IV. Provider business mailing address

5153 COCOPLUM AVE
MELBOURNE FL
32940-1400
US

V. Phone/Fax

Practice location:
  • Phone: 321-271-5403
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MIGUEL URENA
Title or Position: PHYSICAL THERAPIST/OWNER
Credential: DPT,OCS
Phone: 321-271-5403