Healthcare Provider Details

I. General information

NPI: 1942502265
Provider Name (Legal Business Name): SUNSTATE REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2010
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 NE 167TH ST
MIAMI FL
33162-3401
US

IV. Provider business mailing address

58 NE 167TH ST
MIAMI FL
33162-3401
US

V. Phone/Fax

Practice location:
  • Phone: 305-956-7787
  • Fax: 305-956-7716
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JERRY TISHMAN
Title or Position: MGR
Credential: DC
Phone: 561-487-7200