Healthcare Provider Details

I. General information

NPI: 1760412704
Provider Name (Legal Business Name): PROFESSIONAL REHABILITATION CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6595 NW 36TH ST SUITE 202
VIRGINIA GARDENS FL
33166-6979
US

IV. Provider business mailing address

6595 NW 36TH ST SUITE 202
VIRGINIA GARDENS FL
33166-6979
US

V. Phone/Fax

Practice location:
  • Phone: 305-666-2888
  • Fax:
Mailing address:
  • Phone: 305-666-2888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberHCC4495
License Number StateFL

VIII. Authorized Official

Name: ROBERT DE LA RIVA
Title or Position: DIRECTOR
Credential:
Phone: 305-666-2888