MEDICARE: ROCK STAR REP 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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1871734541
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROCK STAR REP INC

Provider Business Mailing Address
First Line	:	5305 OAKWAY DR
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33805-8584
Country	:	US
Telephone Number	:	863-513-0349
Fax Number	:	863-248-0453

Provider Business Practice Location Address
First Line	:	10065 US HIGHWAY 98 W
Second Line	:	STE B 101
City	:	MIRAMAR BEACH
State	:	FL
Zip	:	32550-4924
Country	:	US
Telephone Number	:	850-837-8005
Fax Number	:	850-837-4352

Authorized Official
Title or Position	:	CEO
Name	:	PERRY MONTY REEVES
Credential	:
Telephone Number	:	863-513-0349

Provider Enumeration Date	:	03/10/2009
Last Update Date	:	04/09/2009

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Directions to “ROCK STAR REP INC ” Practice Location

Language	Start Address	Practice Location

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