=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780636878
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERVICE MEDICAL REHABILITATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3750 W 16TH AVE SUITE 140 U
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33012-4654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-826-5567
-----------------------------------------------------
Fax | 305-826-5568
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3750 W 16TH AVE SUITE 140 U
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33012-4654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-826-5567
-----------------------------------------------------
Fax | 305-826-5568
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JUAN A NIEVES SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-826-5567
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number | 600195-2
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------