Healthcare Provider Details

I. General information

NPI: 1598065732
Provider Name (Legal Business Name): INDIAN RIVER REHABILITATION MEDICINE CLINIC P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2010
Last Update Date: 11/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 17TH STREET
VERO BEACH FL
32960-5518
US

IV. Provider business mailing address

P O BOX 2692
VERO BEACH FL
32961-2692
US

V. Phone/Fax

Practice location:
  • Phone: 772-778-1603
  • Fax: 772-231-8470
Mailing address:
  • Phone: 772-778-1603
  • Fax: 772-231-8470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME79198
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME79198
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberME79198
License Number StateFL

VIII. Authorized Official

Name: DR. IHEONU USOUWA ORIAKU
Title or Position: PRESIDENT/ MEDICAL DIRECTOR
Credential: M.D.
Phone: 772-643-4208