Healthcare Provider Details

I. General information

NPI: 1568733020
Provider Name (Legal Business Name): LAVIE REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2012
Last Update Date: 01/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

626 N TYNDALL PKWY
PANAMA CITY FL
32404-6132
US

IV. Provider business mailing address

802 FLIGHT AVE
PANAMA CITY FL
32404-5967
US

V. Phone/Fax

Practice location:
  • Phone: 850-871-3836
  • Fax:
Mailing address:
  • Phone: 850-819-4911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberFL OTA 303
License Number StateFL

VIII. Authorized Official

Name: CHRIS A MANFREDI
Title or Position: COTA/L
Credential:
Phone: 850-819-4911