=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942283379
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST LEE COUNTY REBABILITATION CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1150 LEE BLVD SUITE C
-----------------------------------------------------
City | LEHIGH ACRES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33936-4805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-369-0577
-----------------------------------------------------
Fax | 239-369-7540
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1150 LEE BLVD SUITE C
-----------------------------------------------------
City | LEHIGH ACRES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33936-4805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-369-0577
-----------------------------------------------------
Fax | 239-369-7540
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR & PHYSICAL THERAPIST
-----------------------------------------------------
Name | MR. CARLO T PENARANDA
-----------------------------------------------------
Credential | REGISTERED PT
-----------------------------------------------------
Telephone | 239-369-0577
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | PT0004617
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------