Healthcare Provider Details

I. General information

NPI: 1649728064
Provider Name (Legal Business Name): SUPERIOR CARE REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 8TH ST N
NAPLES FL
34102-5519
US

IV. Provider business mailing address

1065 DIANA AVE
NAPLES FL
34103-4845
US

V. Phone/Fax

Practice location:
  • Phone: 239-529-3733
  • Fax:
Mailing address:
  • Phone: 239-572-4779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14774
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number24303
License Number StateFL

VIII. Authorized Official

Name: DIANALYN ESCOBER DE LEON
Title or Position: OWNER
Credential: PT
Phone: 239-572-4779