Healthcare Provider Details

I. General information

NPI: 1891106241
Provider Name (Legal Business Name): NORTHEAST REBOUND PHYSICAL THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 05/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 PRINCE PHILLIP DR
SAINT AUGUSTINE FL
32092-1746
US

IV. Provider business mailing address

148 PRINCE PHILLIP DR
SAINT AUGUSTINE FL
32092-1746
US

V. Phone/Fax

Practice location:
  • Phone: 904-333-9221
  • Fax:
Mailing address:
  • Phone: 904-333-9221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROMMEL ADOLFO MARSON
Title or Position: PHYSICAL THERAPIST/OWNER
Credential: PHYSICAL THERAPIST
Phone: 904-333-9221