MEDICARE: ATLANTIC PAIN & REHAB 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	173000000X	Legal Medicine	OS4139	FL

General Provider Information

NPI Number	:	1477861896
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATLANTIC PAIN & REHAB LLC

Provider Business Mailing Address
First Line	:	12133 PEMBROKE RD
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33025-1727
Country	:	US
Telephone Number	:	954-499-4143
Fax Number	:	954-499-4143

Provider Business Practice Location Address
First Line	:	12133 PEMBROKE RD
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33025-1727
Country	:	US
Telephone Number	:	954-499-4143
Fax Number	:	954-499-4143

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	MARK DEAN KORNHABER
Credential	:	DO
Telephone Number	:	954-499-4143

Provider Enumeration Date	:	09/20/2010
Last Update Date	:	09/20/2010

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