=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679881890
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PALMETTO GENERAL MEDICAL REHAB INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2010
-----------------------------------------------------
Last Update Date | 09/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2604 W 84 ST
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-824-8888
-----------------------------------------------------
Fax | 305-824-8854
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2604 W 84TH ST
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33016-5703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-824-8888
-----------------------------------------------------
Fax | 305-824-8854
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ALBERTO MATOS
-----------------------------------------------------
Credential | P.A
-----------------------------------------------------
Telephone | 305-824-8888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------