=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982993457
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORIDA MEDICAL REHAB GROUP, CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2011
-----------------------------------------------------
Last Update Date | 04/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1560 MATTHEW DR STE B
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33907-1702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-245-7001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1560 MATTHEW DR STE B
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33907-1702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-245-7001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. STEPHEN M LOVELL
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 239-245-7001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH5345
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------