=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003058306
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORIDA REHABILITATION CENTER,INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2009
-----------------------------------------------------
Last Update Date | 04/01/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 913 SW 87TH AVE SUITE 913
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33174-3206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-362-5083
-----------------------------------------------------
Fax | 786-362-5110
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 913 SW 87TH AVE SUITE 913
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33174-3206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-362-5083
-----------------------------------------------------
Fax | 786-362-5110
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. BENITO HERRERA
-----------------------------------------------------
Credential | MASSAGE THERAPY
-----------------------------------------------------
Telephone | 786-362-5083
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247200000X
-----------------------------------------------------
Taxonomy Name | Other Technician
-----------------------------------------------------
License Number | MA 46836
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------