MEDICARE: ST JUDE PROFESSIONAL CARE 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	208100000X	Physical Medicine & Rehabilitation Physician	PT25877	FL

General Provider Information

NPI Number	:	1558743666
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST JUDE PROFESSIONAL CARE INC

Provider Business Mailing Address
First Line	:	9806 PINES BLVD
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33024-6141
Country	:	US
Telephone Number	:	786-663-6394
Fax Number	:	954-367-5246

Provider Business Practice Location Address
First Line	:	9806 PINES BLVD
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33024-6141
Country	:	US
Telephone Number	:	786-663-6394
Fax Number	:	954-367-5246

Authorized Official
Title or Position	:	OWNER
Name	:	NICOLE NICODEMO
Credential	:	PT
Telephone Number	:	786-663-6394

Provider Enumeration Date	:	06/25/2015
Last Update Date	:	02/18/2016

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