MEDICARE: HYBRID REHAB & PERFORMANCE 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	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1679203749
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HYBRID REHAB & PERFORMANCE LLC

Provider Business Mailing Address
First Line	:	6708 MIRROR LAKE AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33634-1065
Country	:	US
Telephone Number	:	813-454-3377
Fax Number	:

Provider Business Practice Location Address
First Line	:	6708 MIRROR LAKE AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33634-1065
Country	:	US
Telephone Number	:	813-454-3377
Fax Number	:

Authorized Official
Title or Position	:	OWNER/OFFICER
Name	:	DR. ERMIYAS GHEBRAI
Credential	:	DC
Telephone Number	:	813-454-3377

Provider Enumeration Date	:	06/13/2022
Last Update Date	:	06/13/2022

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