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General NPI Number Information
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NPI Number | 1073918371
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Entity Type | Organization
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Legal Business Name | PAIN AND SPINE PHYSIO REHAB LLC
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Dates
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Enumeration Date | 10/29/2014
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Last Update Date | 03/24/2015
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Provider Practice Location Address
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Address Line | 100 SOUTHPARK BLVD SUITE 408 B
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-5189
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Country | US
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Telephone | 518-407-3422
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Fax |
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Provider Business Mailing Address
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Address Line | 100 SOUTHPARK BLVD SUITE 408-B
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-5189
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Country | US
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Telephone | 518-407-3422
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Fax |
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Authorized Official
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Title or Position | AMBR
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Name | MR. REGINO IRWIN B REYES
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Credential | PT
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Telephone | 518-407-3422
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0400X
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Taxonomy Name | Rehabilitation Clinic/Center
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License Number | PT0007862
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT7862
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License Number State | FL
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