=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295715381
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST COAST REHAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4048 EVANS AVE STE 203
-----------------------------------------------------
City | FT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33901-9322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-275-6250
-----------------------------------------------------
Fax | 239-275-6350
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4048 EVANS AVE STE 203
-----------------------------------------------------
City | FT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33901-9322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-275-6250
-----------------------------------------------------
Fax | 239-275-6350
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | LUIS DULUC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 239-275-6250
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT5602
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------