=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285967505
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. JUDES REHAB SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2009
-----------------------------------------------------
Last Update Date | 06/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6595 NW 36TH ST # C218
-----------------------------------------------------
City | VIRGINIA GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-6979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-526-1408
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3900 NW 79TH AVE STE 468
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-6548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-648-6220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. LEONARDO A CHAVEZ
-----------------------------------------------------
Credential | M.A
-----------------------------------------------------
Telephone | 305-648-6220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------