=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952733586
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORA REHABILITATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2013
-----------------------------------------------------
Last Update Date | 08/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1590 S STATE ROAD 15A
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-7817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-734-9400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1110 SHAWNEE RD
-----------------------------------------------------
City | LIMA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45805-3529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-221-6710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | ANDREA K BEACH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-221-6710
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320700000X
-----------------------------------------------------
Taxonomy Name | Physical Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | 320700000X
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------