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General NPI Number Information
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NPI Number | 1770855934
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Entity Type | Organization
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Legal Business Name | LAVIE REHAB
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Dates
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Enumeration Date | 02/03/2012
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Last Update Date | 02/03/2012
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Provider Practice Location Address
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Address Line | 636 TYNDALL PKWY
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City | PANAMA CITY
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State | FL
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Zip | 32404
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Country | US
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Telephone | 850-871-6363
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Fax |
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Provider Business Mailing Address
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Address Line | 10210 HIGHLAND MANOR DR STE 270
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City | TAMPA
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State | FL
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Zip | 33610-9151
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OCCUPATIONAL THERAPIST
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Name | MS. KRISTEN JAMES JACKSON
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Credential | OTR/L
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Telephone | 850-832-8071
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | OT11464
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License Number State | FL
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