=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467236943
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOLISTIC REHAB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2023
-----------------------------------------------------
Last Update Date | 08/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 CALLE 5 BLOQUE C ESTANCIAS DE SAN FERNANDO
-----------------------------------------------------
City | CAROLINA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-637-4897
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1299 W BOSH APT 906 TERRAZAS SAN JUAN
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00924-4668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-637-4897
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MBR
-----------------------------------------------------
Name | LYNETTE RIOS RODRIGUEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-637-4897
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------