=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982216321
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DM REHAB CORE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2020
-----------------------------------------------------
Last Update Date | 08/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 289 SW STONEGATE TER
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32024-3456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-401-4309
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3985 NW COLONIAL GLN
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32055-4857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARQUS FISHER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-401-4309
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------