=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831900760
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JUPITER FL REHAB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2025
-----------------------------------------------------
Last Update Date | 01/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17781 THELMA AVE
-----------------------------------------------------
City | JUPITER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33458-7942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-619-4897
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 BRIGHTON RD STE 204
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07012-1668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-613-4386
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | YECHEZKEL AMOYELLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 326-194-8977
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------