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NPI Code Detail

MEDICARE: PREMIER ATHLETIC REHAB CENTER LLC

MEDICARE: PREMIER ATHLETIC REHAB 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
1261QP2000XPhysical Therapy Clinic/CenterPT25977FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1Y07QROTHERFLBCBS
22801168OTHERFLCIGNA

General Provider Information

NPI Number : 1194082909
Entity Type Code : Organization
Provider Name (Legal Business Name) : PREMIER ATHLETIC REHAB CENTER LLC
Provider Business Mailing Address
First Line : PO BOX 450844
Second Line :
City : MIAMI
State : FL
Zip : 33245-0844
Country : US
Telephone Number : 305-396-9002
Fax Number : 305-390-3003
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 : 305-396-9002
Fax Number : 305-390-3003
Authorized Official
Title or Position : PHYSICAL THERAPIST
Name : ALEJANDRO G GONZALEZ
Credential : DPT
Telephone Number : 305-282-7252
Provider Enumeration Date : 04/18/2012
Last Update Date : 11/19/2013

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