Healthcare Provider Details

I. General information

NPI: 1770855934
Provider Name (Legal Business Name): LAVIE REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2012
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 TYNDALL PKWY
PANAMA CITY FL
32404
US

IV. Provider business mailing address

10210 HIGHLAND MANOR DR STE 270
TAMPA FL
33610-9151
US

V. Phone/Fax

Practice location:
  • Phone: 850-871-6363
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberOT11464
License Number StateFL

VIII. Authorized Official

Name: MS. KRISTEN JAMES JACKSON
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTR/L
Phone: 850-832-8071