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General NPI Number Information
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NPI Number | 1912206772
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Entity Type | Organization
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Legal Business Name | PREMIER REHABILITATION GROUP, LLC
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Dates
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Enumeration Date | 03/19/2011
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Last Update Date | 03/19/2011
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Provider Practice Location Address
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Address Line | 7980 NW 155TH ST STE A
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City | MIAMI LAKES
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State | FL
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Zip | 33016-5884
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Country | US
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Telephone | 305-822-6812
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Fax | 305-822-6813
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Provider Business Mailing Address
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Address Line | 7980 NW 155TH ST STE A
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City | MIAMI LAKES
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State | FL
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Zip | 33016-5884
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Country | US
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Telephone | 305-822-6812
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Fax | 305-822-6813
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Authorized Official
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Title or Position | PRESIDENT-OWNER
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Name | LIDICE CARBONEL
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Credential | LMT
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Telephone | 305-822-6812
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0400X
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Taxonomy Name | Rehabilitation Clinic/Center
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License Number | MM26565
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License Number State | FL
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