MEDICARE: GABLES INJURY & SPORTS THERAPY CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HCC9122	OTHER	FL	AHCA NUMBER

General Provider Information

NPI Number	:	1154612364
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GABLES INJURY & SPORTS THERAPY CENTER LLC

Provider Business Mailing Address
First Line	:	3121 PONCE DE LEON BLVD
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33134-6816
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3121 PONCE DE LEON BLVD
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33134-6816
Country	:	US
Telephone Number	:	786-953-8378
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ALEJANDRO LOPEZ
Credential	:
Telephone Number	:	786-953-8378

Provider Enumeration Date	:	04/21/2011
Last Update Date	:	02/01/2012

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