=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063784528
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORAL REHAB, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2012
-----------------------------------------------------
Last Update Date | 01/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2721 SW 137TH AVE STE 113
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33175-6355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-364-5245
-----------------------------------------------------
Fax | 305-364-5269
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2721 SW 137TH AVE STE 113
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33175-6355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-364-5245
-----------------------------------------------------
Fax | 305-364-5269
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SILVIA SANTIESTEBAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-364-5245
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | MM28057
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------