MEDICARE: BLUE HEAVEN REHABILITATION INC

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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1497042253
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE HEAVEN REHABILITATION INC

Provider Business Mailing Address
First Line	:	4355 W 16TH AVE
Second Line	:	SUITE 201
City	:	HIALEAH
State	:	FL
Zip	:	33012-7666
Country	:	US
Telephone Number	:	305-551-2400
Fax Number	:	305-551-3989

Provider Business Practice Location Address
First Line	:	4355 W 16TH AVE
Second Line	:	SUITE 201
City	:	HIALEAH
State	:	FL
Zip	:	33012-7666
Country	:	US
Telephone Number	:	305-551-2400
Fax Number	:	305-551-3989

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ALFREDO NODARSE
Credential	:
Telephone Number	:	305-551-2400

Provider Enumeration Date	:	06/30/2011
Last Update Date	:	06/30/2011

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