=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992144141
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORIDA FALL PREVENTION AND REHABILITATION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2013
-----------------------------------------------------
Last Update Date | 10/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 850 LOGGERHEAD ISLAND DR
-----------------------------------------------------
City | SATELLITE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32937-3845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-508-3250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 850 LOGGERHEAD ISLAND DR
-----------------------------------------------------
City | SATELLITE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32937-3845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-508-3250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARK ALAN BRIMER
-----------------------------------------------------
Credential | PH,D,, PT
-----------------------------------------------------
Telephone | 321-508-3250
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | L13000085254
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------