MEDICARE: CONCENTRA

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	261QH0100X	Health Service Clinic/Center	PA2569	FL

General Provider Information

NPI Number	:	1306161666
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONCENTRA

Provider Business Mailing Address
First Line	:	6301 NW 5TH WAY
Second Line	:	SUITE 550
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33309-6131
Country	:	US
Telephone Number	:	954-731-9444
Fax Number	:	954-491-8787

Provider Business Practice Location Address
First Line	:	6301 NW 5TH WAY
Second Line	:	SUITE 550
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33309-6131
Country	:	US
Telephone Number	:	954-731-9444
Fax Number	:	954-491-8787

Authorized Official
Title or Position	:	PHYSICIANS ASSISTANT
Name	:	MR. HENRY A LOCUS
Credential	:	PA
Telephone Number	:	954-731-9444

Provider Enumeration Date	:	03/30/2010
Last Update Date	:	03/30/2010

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