MEDICARE: LIFE WELLNESS REHAB CENTER CORP

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

General Provider Information

NPI Number	:	1710379979
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE WELLNESS REHAB CENTER CORP

Provider Business Mailing Address
First Line	:	6447 MIAMI LAKES DR E STE 222E
Second Line	:
City	:	MIAMI LAKES
State	:	FL
Zip	:	33014-2764
Country	:	US
Telephone Number	:	786-219-9748
Fax Number	:	786-219-9748

Provider Business Practice Location Address
First Line	:	6447 MIAMI LAKES DR E STE 222E
Second Line	:
City	:	MIAMI LAKES
State	:	FL
Zip	:	33014-2764
Country	:	US
Telephone Number	:	786-219-9748
Fax Number	:	786-219-9748

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RICARDO M ACOSTA
Credential	:
Telephone Number	:	305-219-9748

Provider Enumeration Date	:	02/25/2015
Last Update Date	:	02/25/2015

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